Thank you everyone for spending the last of the Friday sessions with us. My name is Sean Smith. I am from the University of Michigan and I have the fun, but some would say easy, job of introducing some very good speakers and then moderating a discussion later. The discussion, just for some housekeeping, any Q&A is going to be done through the app. This is being streamed virtually, so you've all at home in your underwear, type through the app. Everybody here, hopefully wearing more than their underwear, also type in the app, okay, and we will at the end kind of have everything in one area and we'll be able to talk. So this is, this is a discussion that's quite frankly a few years in the making. It is existential, it's metaphysical, and the title, I'm going to jump back a slide if I can, has those words, right, it's essential, this is knowledge and skills, it's the result of a working group, it sounds really important, and it is really important. What it is, is a result of the AAPM&R's initiative that started a few years ago, VOLD. As you can see, cancer rehabilitation was selected as one of the kind of first target areas for this, this initiative, and the initiative is to do what it sounds like, which is to say, what is it that we really need to do to get ourselves on the map? The Academy saw that there's sort of threats coming from different sides, and you know, what are some areas of practice that we should really highlight and enhance? And I am fortunate to be up here talking about this because they chose cancer rehabilitation medicine. On the far right, you can see this sort of envisioned future that came out of this think tank that was spent in a locked room at Rosemount, Illinois, a few years ago. It's nothing controversial, basically, that we think we should be recognized as the experts that we are. When appropriate, we should be integrated into oncology care, and that recognition should extend beyond, say, a medical oncologist, it should be system-wide. But getting to that is the challenging part, and so to figure out what it is that we have to recognize and how to get people to recognize it, we have to sort of reckon with what it is that cancer rehabilitation medicine is. And so at that roundtable at Rosemount, I was sitting next to David Zucker in Seattle, who has a completely different practice pattern than I do. Across the table was Michael Stubblefield, Andrea Chaville, Julie Silver, and others who all have immense contributions to the field, but also different contributions. And so what is it that sort of unifies us all and makes us cancer rehabilitation physiatrists? Okay, what are the common core services that we offer? What are the overlap with general physiatry? Taking that a step further, how should we be training the cancer rehabilitation physiatrists of tomorrow, and how is that different or complementary to what the training of general physiatrists is? And this talk today is going to sort of be the origin story of our field, even though it's existed for decades technically, but it's a result of a painstaking and iterative process from a lot of people. Folks at that original roundtable that represent a range of physiatrists at different stages in their career, different geographic regions, and then a subgroup that kind of popped off of this that you can see the the folks here. I believe all of them are here in attendance. And from this, we sort of started generating, talking about those big questions as led by Mary and Eric, you know, what is it that we that we do? What is it that we have to learn and teach the next generation to get that recognition? And so we gathered input from the community along the way. This wasn't a closed-door ivory tower meeting. We talked to some of you at the virtual learning collaborative, and we're going to share this with you today. It's available online. It's available, there is a URL that I don't think quite made the update slides right now, but if you need some light reading, it's about 55 pages. And we'll go over the highlights of it today though. We're published in the Purple Journal now. So with that, I'm going to introduce Mary, but before I do that, I'm going to talk about a poll. So we're gonna have a few different audience participation questions that includes you at home. So if you can snap the QR code, this is the easiest way to do this. On the next slide is going to be the question and a URL, which is a longer way to do it. So I'll give everybody a second. We're going to start with a light question. What is the key 67 proliferation rate of a malignant tumor that needs to necessitate a functional goals of care? I'm just kidding. The actual question is, what career stage are you in? So please answer that, and then I will pass that on to Mary once we have some results. So give this a second. Yes. And again, the URL is on the results page too, if folks need this. So, all right. Well, most of us are in that. It's a pretty good range actually. So good. Okay, a little over 50% are attending and beyond, but a whole bunch are not. So that's really encouraging for the future of this field, because we need you all. So without further ado, Dr. Vargo is going to talk about the core services component. Hello everyone. Sean already mentioned the think tank from 2018, and I did want to refer back to this for core services. I did list the participants there of the think tank. I think they should be recognized. Almost all cancer rehab physiatrists. And from this, AAPMNR's strategic plan for cancer rehabilitation was born really. And we've been talking, you know, about the need to delineate what are the real core elements of cancer rehabilitation, you know, on and off pretty much forever. But we just never quite, you know, consolidated around getting the traction to do it. And so as part of this strategic plan, really core services delineating that was identified as priority number one for the cancer rehab strategic plan. So this was the first step we undertook, and with Eric and I as the initial AAPMNR BOLD co-chairs for cancer rehab medicine. So you'll see that acronym CRM throughout at least my slides. And now Sean and I. So the first project was to focus on these core services. And the goals of core services really... sentence number one here is the most important sentence in my whole part of the PowerPoint. Cultivate universally understood standards of what a referring oncologist and the public can expect from physiatry. So just pretend I said that five times. So that's really, you know, what this is about. So the idea is to have, you know, consistency. Not that every cancer rehab physiatrist is going to have exactly the same skill set, exactly the same practice. Not that all programs are going to look exactly alike. There's always going to be, you know, relative strengths. There's going to be differences. But at the same time, this recognition that there also needs to be, you know, some consistency. And then, you know, value. I think it's more helpful maybe to look at this from the converse side. That if referring providers and the public, you know, don't know what to expect. If we don't have enough consistency that others know what to expect, you know, we're not going to be valued. So, you know, one is needed in order to have the other. So, growth. That framework that having the core services provides, you know, allows us to develop more well-rounded programs. It serves as a guide for new programs to design themselves around. And then, of course, knowledge. So, it assists with identifying priority areas for education and research. Just an overview. Predominantly, the core services, as you'll see, consists of clinical areas of expertise. We also included procedures and then some content related to areas and settings of practice. And it's primarily meant as a sort of externally facing paradigm. So, to let others, you know, outside of our world know, you know, what we do. So, it's directed towards patients, caregivers, oncology care teams, even payers, leaders of health systems. So, primary intent to get the word out about what we do. So, it's sort of an externally driven tool. So, we can use it internally as well. So, just a little bit more on process. Just so you don't think we just sat in a room and came up with this. Starting around May or June of 2019, Eric Wasatsky and I, as the CRR co-chairs, well, we did sit in a room and came up with a draft outline of what core services might look like. But then afterwards, it was this sort of undulating process of reaching out and then gathering back in and synthesizing what we were learning and so forth. So, the first thing was a very detailed survey, and I'll show you a snippet from that, which had about 60 responses. Then back in 2019, there was a learning collaborative. I'm sure many of you were there. It probably had close to 100 people where we went through the survey results. Also, I had some talks on some sort of flashpoint topics related to core services. Then we took that information back and worked on the core services some more. This is just an example of the survey. The survey was really informative. We didn't necessarily take the results literally, and that turned into core services, but it gave us just some more substrate to consider how to prioritize these different areas. You can see on the left-hand side is some different focus areas within cancer rehabilitation. Then we asked the respondents in their own practice on a one-to-five scale, how important is this? Then we also asked them, ideally, how important should it be in cancer rehab physiatry practice? We actually asked for similar responses with regard to program as opposed to person, the physiatrist, although that didn't really yield too much of a different perspective from just asking about them. Not surprisingly, some of the higher yielding areas were rehab during treatment, breast cancer rehab, peripheral polyneuropathy, exercise, head and neck cancer rehabilitation. Those all got more than a four for actually now, which actually now has the most face validity. Then also, of course, scored high in an ideal practice. You'd also see that. Whereas on the other end of the spectrum, the lower numbers where people were really not doing that in their current practice were things like sexuality, ultrasound diagnostic, evaluation, nutrition, pediatric, cancer rehab. Not that those areas aren't important, but we're just not there yet to say that you could expect those things of your typical cancer rehab physiatrist. We just had ongoing refinement of that over the next year or two. In the spring of 2021, we did a second survey, much more abbreviated than the first one. Then there was a comment period about the final core services and another learning collaborative, which was virtual in June of 2021. It was approved by the AAPMNR Board of Governors in September 21. The general outline, there's five major categories. Global impairment, symptom specific, cancer diagnosis specific, procedures, wellness survivorship, and areas of practice other. There's also an element of having levels to it, so areas where all cancer rehab medicine physiatrists would be expected to have some knowledge and competency regarding. Then others, maybe only some specialized CRM physiatrists would be expected. We kind of toyed with having an all physiatrists category to it as well, but that got really complicated and it just seemed more cumbersome than helpful to have that element to it. Although curriculum does get to your expectations for say a physiatry resident, so that does split some hairs that core services doesn't. Try to keep this simple. So I'm not going to read through every line item in here, but this is what global impairment symptom specific category contains. So you can see it starts with a mobility related impairments and physical function, so the very basic and global. And then the next one relates to pain, so we purposely put diagnosis and treatment of pain related to cancer and cancer treatment. All of these really relate to diagnosis and treatment, obviously, but we really wanted to highlight that with pain. And then the next one is musculoskeletal neuromuscular disorders in cancer, followed by cancer related neuropathies, which of course neuropathies are neuromuscular, but we just thought neuropathy is prominent enough in its own right in cancer rehabilitation that we gave it its own line item there. And on down in the green print we said bone health strategies. That might only be expected of some specialized CRM physiatrists. So rehab management for bone metastasis, all CRM physiatrists, but bone health sort of beyond that, a little bit more specialized. And then cancer diagnosis specific, I'll just let you read that list. So it starts with breast as many of us, you know, have that as a very, you know, predominant part of our practice. And the other areas, of course, are important. Procedures. This was kind of a thorny one of, you know, how to consider procedures because we have the aspect of, you know, our own individual competency, our skill in doing the procedures, but then there's also the aspect of patient care and maybe we don't do all these procedures, but the important thing is to recognize in our patient care when a patient might benefit and know what procedures are out there and navigate the patient to that care. Of course they're both very important and again in curriculum it does split those hairs a little bit more, but for purposes of core services we took it to be from the point of view of the physiatrist being able to do the procedure or being expected to do the procedure. So the top three, the landmark guided office injections, EMG and Botox for spasticity, those were the common ones because most of us, you know, would be generally expected to get that in residency, whereas the others are more specialized. There's also, of course, some of these might be from non-cancer rehabilitation specialists, like say pain specialists, so we know that as well. They're just more specialized procedures. Wellness survivorship, a variety of things here. Employment, disability, community, exercise and cancer, of course is a big one. Prehab and survivorship we put in this grouping, and then with nutrition and sexuality in the some specialized category. Areas of practice, this is kind of a mix. Settings of care, inpatient, acute, outpatient, inpatient, acute rehab. Also assessing level of care, team leadership and care coordination, and then phases of care. So at the advanced cancer patient, rehab during treatment, and as I mentioned we already have prehab and survivorship in the other category. There's also one on sort of DME related with prosthetics, orthotics and adaptive equipment, and then we put pediatric cancer rehab and complementary and integrative strategies as more of a more specialized items. So you know just stepping back and thinking about the applicability of this, you know even though I said it's mostly, you know, externally focused, we still can look at ourselves and identify our areas of strength, you know, and solidity within these. And then also areas where we might aim to improve, especially as we look at our own practice settings and you know what the needs might be. And then of course there's our own programs and having our programs be as well-rounded as would be optimal and use this as a guide towards getting there, towards advocating with our administration for support, you know, that we need this. Beyond that, you know, locally our own institutions, our cancer center to help get the word out. You know sometimes like not every provider in the cancer center as we well know, might not know what we do. You know I've certainly been asked, oh you can do something besides lymphedema? You can treat fatigue? Or you know just not everybody knows, you know, what we do even though we sometimes assume they do. So you know it can be presented, you know, to our institutional cancer committee or the board of the cancer center or give a talk or there might be patient support groups or just, you know, for us all to look at our institutions and what are the opportunities there or in the community at large, a community cancer organizations that we all may have or even other medical institutions in the community that may not be known for cancer rehab services but could benefit some of their patients. And even, you know, beyond that, we honestly don't even really know where this is going beyond, you know, laying it out now. Certainly one step is that it's been used as a framework for the curriculum that you'll hear about momentarily and we have some ideas of, you know, further, you know, how we can promote this but we're also interested in hearing, you know, from others and how we might further this along. So before I hand over to Eric, there's... I think if you have the QR already from the previous question, it should work but I'll still just take a moment. Everyone good? So you can, you don't have to limit yourself to one. Oh okay, could add answers in the chat, is that what you said? Okay. Okay, so the most common was marketing your practice to oncology teams. Okay, very good. And now we are going to try a word cloud. Yeah, so what words come to mind as you reflect on the utility of the core service? Mm, that's a good question. And now we'll hear from others, starting with Eric, about curriculum. Thank you, Mary. It's so great to see so many of you here today. You know, this is kind of a wonky talk. We're not going to be teaching you any clinical pearls about cancer rehab today, so all of you must care about building the specialty because this is really what that's all about. So that's exciting. And I will say from that word cloud, I think one word that I saw in there that I think was quite poignant, you might not think so, was hmm. As we transition to the core curriculum now that we developed after working on the core services, we actually just vetted some of these core curriculum items, not just for cancer but for other specialty areas with PM&R program directors earlier today at the GME Summit. And there were a lot of hmms, and it's a lot of questions. And I think some of what we're presenting today in some ways creates more questions than answers, but that's why we're here, to discuss it and figure out how we can utilize the work that's been done. So myself, Dr. Rupert, and Dr. Shapar will be talking to you about the curriculum that we worked on together after the core services. So this was just published in this month's PM&R Journal, so please take a look at the summary statement as well as the link to the entire curriculum itself. So what we're trying to do here, to generally guidelines for training, primarily for individuals involved in teaching residents and fellows, so general guidelines is one thing to keep in mind. And then a secondary audience is for those out in practice. And as the PM&R BOLD effort continues on forward, you know, one of the potential next steps in the future is not just thinking about our residents and fellows, but the CME aspect of this, people who are already out in practice that want to do cancer rehabilitation and how we can help support those folks to provide great care to our cancer patients. And this is where it gets a little tricky, so meant to augment rather than supplant the role residency and fellowship directors and faculty play. This is not intended to say scrap everything you're doing and do this, probably not actually feasible in some ways, but really hopefully a helpful guide to give people a number of ideas on how they can support their educational programs. And this is another important point. It's really intended to focus on what should be, this is aspirational. So as my colleagues today give you kind of a sneak peek at some of the components of the curriculum, you're going to have all kinds of thoughts and some of them are going to be like, how do we do that? And that was kind of our intention. It was really in a dream world, what would we love our physiatrists graduating from residency to know, to take great care of these patients? What would we love our fellows to all know after just one year of a fellowship where there's a lot of heterogeneity between the programs? So if you're saying, I don't know how we can do this, that's okay because it's aspirational. And then in terms of our work group, how we did this, as we talked about, we had our amazing work group, which has been amazing working with these colleagues, and it was really our expert consensus, but there were other stakeholders involved, as we'll talk about. So in terms of the process here, so we were defining knowledge, skills, and attitudes, as you'll see, to be proficient in practicing CRM. And this was, as Mary stated, this is aligned with the core services that you saw. So all of the major subsections of the curriculum line up with the core services, except for the one on the bottom, general education, which is kind of its own separate area, as we'll discuss. So in terms of the structure of what this looks like, and we'll give you a headache looking at a lot of these coming up soon, but you'll essentially see that on the left side of the table is kind of all of our learning objectives and topics, things that we want people to learn, and then we labeled each of them as a knowledge, skill, or attitude. And then we essentially defined it as core to all physiatrists, so essentially, do we want every physiatrist that graduates from a PM&R residency to know this? Or is this something more specialized, that we might only expect someone who had done advanced training after residency to know, essentially? And you can see that here, and we have sub-settings under each of basic, intermediate, and advanced. And I think as a rough framework, there's different ways to interpret this, but for the core part of this, numbers one, two, and three, so that might be an early resident, someone in the middle of training, and then maybe someone who's just graduated, or maybe someone who goes to a program that maybe has more cancer rehabilitation education than others. And on the specialized side, this is really what that accounts for, so many differences between different cancer rehab doctors out there, that those of us that are specialized were not all the same, and that number six, advanced, there may only be a smaller sub-set of cancer rehab specialists that maybe practice in these certain areas that might fall under number six, if you will. So there's that. We did vet this with a larger group in a virtual collaborative in 2021, so before this went officially public, we really wanted to make sure this was vetted. And that was an amazing meeting, and we got a lot of really, really great input that night out of looking at a 50-something page document, it was a lot to go through, but that we did incorporate into this quote final product, which, oh by the way, is not necessarily a final product, this is something that is a living document that we'll continue to modify as we go forward. Yes. So now we're going to transition to going through some of the specific sections and kind of highlight some of these things to you. And one thing I just wanted to mention, as we look at, just backing up here, another thought that you will have in your head today is you're going to see a bunch of Xs as we kind of labeled things, one, two, three, four, five, six, and you're going to say, why is that a five? Why is that a two? That's exactly what we did, and it would be super easy for all of us to sit in a room and argue for one hour over one X, and you guys could all do the same thing. So we had to come to a decision somewhere, but we will definitely concede that a lot of these things are absolutely debatable. So that's a disclosure. So let's start talking about some of the subsections of the curriculum, and I will call up Dr. Rupert from Memorial Sloan Kettering to continue. Thank you. So as both Mary and Eric have already alluded to, we really tried hard to align the curriculum to those core services. What is it that we're learning and training that we've brought with us along the way that makes us who we are, and what do we think that, you know, would be good for our residents and like Eric said, our fellows to learn? So we broke them down into the competencies of global impairment, symptoms specific, cancer specific, excuse me, cancer diagnosis specific, procedures, areas of practice and other, wellness and survivorship, cancer rehab related standards, outcome measures, and program building. Within each of these competencies, we broke them down into smaller categories, and here we did try to be somewhat consistent in what these categories were. So we looked at mobility related impairments and physical performance, neuromuscular effects, and whenever there was an overlap to another area, we did try to tie it in so that you would know that this may also be repeated somewhere else or you could refer to another section if you wanted to see more about it. Cognitive impairments, lymphedema, cancer related fatigue, pain and symptom management, bone metastasis, radiation fibrosis, and psychological symptoms. We then broke it down even further because we were really trying hard to figure out what is it that we're rating and what aspects of things are we rating. So within each of those categories fell the subcategories and these were history, functional review, physical examination, medical knowledge, and here we started to bring in more specific diagnoses, specific causes, anatomy and physiology, classification systems, wherever they were applicable, diagnostic and functional measurements, management, any kind of precautions or special considerations such as any kind of complications that you may see, specific symptoms related to these treatments, any kind of medications or interventions that we may recommend or things that we'd have to be mindful of if we are recommending and making sure we're recommending it for the right patients, and also education. And you can see this is where the X's start to fall. And we already alluded to, all of us came from different programs. We had different exposure to cancer rehab. I was very fortunate as a New York Presbyterian resident that I spent time at Sloan Kettering so I had a very robust cancer rehab experience, but not everyone has that. And sometimes we rely on our colleagues in other areas of rehab to kind of fill in some of that knowledge for us or we rely on lectures or different kind of educational programs that we're building for our trainees. And so we did have a lot of debate. So there was times where I thought, no, but our residents know this and someone else would have to remind us that, you know, yes, yours do, but ours may not see that. So there was a lot of back and forth. Sometimes there was overlap. And sometimes we just kind of met in the middle as to where it could possibly be. So I know this is a lot on a slide, but this is actually what the document looks like if you see it in real life. So I chose to look at the global impairment in some specific category. And within this, the first, you know, subcategory we looked at was mobility related impairments and physical performance. And we started with the history. What are we asking? What are we trying to obtain? Do we think that there are certain aspects that are more knowledge-based? You should really know what kind of impairments you're looking for, when they started, the location, how they've progressed. That's more of a knowledge, but maybe it's a skill to know to ask that. Similarly, recognizing chemotherapeutic agents and knowing their side effects, radiation, what structures may be involved. Those are knowledge pieces that we would expect our trainees to know. But otherwise, asking the history, a lot of that's skill. So different things that we're taught to ask about. And then when are we taught to ask about those things? So oftentimes, there's a good amount of our history that we expect our early trainees to know when it comes to mobility and falls and what might be impacting mobility. But then there's some, when we start thinking more about the treatment-related or specific structures, we may be expecting a little bit more of our intermediate or advanced. Or perhaps we don't actually think our residents will see this or know this. So what about those neuromuscular effects of a particular cancer type or a particular treatment? Maybe that's something that we're expecting our fellows are going to learn. We acknowledge that not everyone is going to see this, because not every institution is treating certain things. So it really kind of was a lot of back and forth of where. I think also what we looked at was, where else are we asking these questions? Are we asking stroke patients these questions? Are we asking patients with neuropathies for other reasons these questions? Can we tie that in somehow, where really we can say, you know what, maybe they're not learning about a cancer patient with this, but they've heard this. And we would expect that they're learning this during their residency. We did this similar for functional review and also for our physical exam. Then we started thinking about the medical knowledge that they would need to know. What is it that you need to know about mobility impairments? What is it that, you know, we would want to know that's coming from a certain condition or a certain treatment? How do body mechanics impact this? What kind of adaptive equipment? And again, where are our residents hearing this? Where are our fellows hearing this? You know, how much of this is knowledge or skill? And how far along the way do we think that they're going to be when we're seeing these things? We did similar for diagnostic and functional measurements. And you can kind of see here, we really started to move more towards skill and more towards advanced, because we realized that, you know, we talk a lot about promise and different functional outcomes, but maybe they're not hearing this so much in training, unless they're working on a research project. But this is something more that we're thinking about, and we're thinking about it more with our fellows. Similarly with management, you may not expect that your early trainees understand how to manage it, but hopefully they can identify it, they can ask about it, and really they're going to start honing in on that management later on. Similarly with precautions and special considerations. You know, the big scary things we think that they should know about, or we should be advising them up front, but some of those nuances, as they're moving along the way, they may not hear too early. Some of those specific complications or considerations, we're thinking about thromboembolic complications, cardiovascular, cancer, cachexia, and sarcopenia. When you think about the things like the thromboembolic and cardiovascular, they may be seeing this in other diagnoses as well, so they may have some background. But when we really start talking about the cancer-specific, we're really understanding that this may come later again. So you can kind of see, we splattered a little bit all over the place. There was a lot of debate about this. These Xs moved a lot. Sometimes these Xs appeared in more than one place because we just couldn't make a decision, and that's where this kind of comes as a living document, and maybe as, you know, we're looking at this and we're looking at our programs and both from the residency standpoint and the fellowship standpoint, these X's may move even more as we're incorporating more and more into this. Cancer diagnosis specific was the second area that we looked at. Again, we did think that a lot of, um, cancer rehab medicine specialists should be able to know the good majority of, but we did acknowledge that there was some areas where more of the nuance might be a more subspecialized cancer physiatrist. We had similar categories as we did for the first group in terms of, you know, the history of the physical exam, in terms of how we broke it down, just showing you we kind of repeated this process for all of these areas. I brought up neurological tumors here and I think where we kind of went back and forth a lot about this was if there was overlap with spinal cord injury for another reason or brain injury from another etiology and we thought there was something about this that our residents did see, then it might, you know, fall earlier on. And also a lot of the basics that we learn in school about various tumor types and where they're presenting, we did think that this would be something that they should know and it's also something that, you know, when we look at what they're doing in terms of board studying and board preparation, it's all fair game on that. So we did anticipate some of this that they should know. But what we did acknowledge is as you moved more towards the management or even more towards some of those subspecialized areas within brain and spinal cord tumors, maybe it's not even all of us that do it. You know, maybe there's a small group of us that are focusing on these certain areas and that's okay too and we did reflect those when we thought it was needed. The last area that I'm going to touch on before handing it on to Sam was procedures. And as you already heard, there's some procedures that we do learn during our training that we do expect that our trainees would know. But then at the same time, there's some that, you know, some of us may have never done. And that's okay. I think the big important part is the knowing that they exist, the knowing who it's right for, and the knowing of who it's not right for. So we did try to break it down into all those various different pieces and we did try to rack our brains about all the various procedures that could be done. And so I did actually pull up ultrasound. You know, there's some aspects of ultrasound that, you know, everyone's learning during training now. I'm a little bit older, it only started coming out towards the end of mine, so maybe I might not agree that I would have learned this so much during training. But others are. But really, when we were looking at a lot of this, we did acknowledge that it would be more specialized, those who were doing specific training to learn about these procedures. But that being said, this is something that we can all incorporate and we should all know at least the information behind it. And one of the things, you know, and Mary actually highlighted it once, and I just want to say before I'm handing it off, was that she was preparing for a talk and she actually went back through this curriculum and she redesigned how she gave her talk based on her audience and what it was that she wanted them to know. And I actually found that I started doing the same thing in preparing mine. So it was a nice way that maybe we're not necessarily looking at big programs and maybe it's not a big picture thing of our ACGM and whatnot. But what can we each do individually when we're teaching, whether it be medical students or residents or fellows, what can we bring to the table, what can we offer, and how can we make sure that we're including all these things so that they're at least having exposure to that. And so with this, I will hand it off. Thank you, Lisa. And we're almost done with looking at tiny print with Xs. I got a few more of those, but it's there. So I'm going to be holding up the back end. And as you see, this is the beginning of my section where I talk about wellness and survivorship. I kind of like to think of some of my sections, they're not necessarily diagnostic specific, but the things I'm talking about are general categories that we think about. And obviously when we think about all of our trainees or when we go through training, we should all be paying attention to everything in that red box over there. And then some more specialized components is nutrition and sexuality. We know that is important in some people's practice and some of us may not have had that training and expertise or we feel comfortable talking about that, maybe we utilize some other services there. What I wanted to kind of pull up is just some of the topics that we put in in terms of when we're talking about survivorship. And I think even our trainees that go through now to our residency programs that have zero interest in cancer rehabilitation, fortunately or unfortunately, they will be seeing patients who have cancer. And so you need to have, even if you don't identify as a cancer rehabilitation specialist, you need to have a basic knowledge. I am going to be seeing someone in clinic next week that one of our MSK specialists saw and they subsequently diagnosed with cancer because the pain was persistent. They're coming to me. And so they had to identify certain things and guidance and paying attention to. So these are some other bigger picture aspects, but I think when we divide this, this is not just, as I mentioned, for our specialty group, but ideas that people should be paying attention to moving forward. And as a lot of the groups said, I am not going to read this. This document is available. It is 50 plus pages. There's a lot to chew on. Hopefully this kind of just gives you an idea of the topics we were considering. Again, just to identify a little of the sexuality component, obviously some of these we would hope that at least some basic knowledge we all have. But in terms of really being able to feel comfortable in guiding, this may be something that we all need some extra training on. Maybe we need to give more talks in these national meetings, workshops, other things to help grow our specialty in terms of what is available in our national community and our local communities to be able to guide patients on this, because this is an important topic for a lot of our patients that are not being met. The next area we talk about are areas of practice. As you'll see, that big red box is a big red box with a bunch of stuff in it. And then the other side is the some specialized. As you end up seeing on both these slides, there's a lot of stuff we want everyone to know. I apologize for my dotted line not being in place, but in terms of thinking that we see, we're talking about consults. We're talking about inpatient rehab, outpatient prehab, discussing the assessment of what level people are appropriate at, and then it was mentioned earlier, things like prosthetics and orthotics and DME, how to manage an interdisciplinary team, and as advanced cancer. Those are necessarily things that we all should be paying attention to. Pediatrics and complementary integrative health, including some of the DOs in our group that is obviously not something... I am not a DO, so I will not have that expertise, but understanding that we may have colleagues or specialists around that may or may not be physiatrists that may be able to help us within that process. And so as we end up thinking about even that big red box, as I kind of broke down again, we're thinking about levels of care, and then we think about across levels of care. And so another kind of process, have we thought about this, of how to break things down. Instead of reading this, I'm going to go and show you these all settings of practice. So these are things that we want everyone to know, and it doesn't matter what level you're doing. You should be paying attention to the common impairments, the diagnoses, how to really assess. I think Dr. Stubblefield and his team back there, I apologize for our OT, I forgot your name, you did a great talk in terms of reviewing the medical record and getting information about it. And so that's a big part that we want all our trainees to do, because it's not just although our physical assessment and getting information from the patient, but we know in our cancer population, really reviewing the medical record, figuring out what information you don't have and what information you have to be able to guide your assessment and plan. And so these aspects are really important for everyone assessing somebody. As I jump and I just take an example of another piece, you'll see on this part, and let's see if I can point on this one, this area of see all settings, see acute inpatient rehab, see this. We try not to be writing the same thing over and over and over again. The document is already really, really long. So if it is referenced somewhere else, we were hoping that you can go look and you still have those skill sets that you need for advanced cancer. You need to pay attention to where they fit on that spectrum, but as well as having some unique aspects in addition to all those C levels that we have over there. And so I use this example for advanced cancer because for those patients, they can be across the spectrum. So there's a lot of that assessment you need in terms of seeing where they're at in addition to making sure you're addressing these other aspects. This is what I ended up calling our variety pack section. I think Eric had mentioned our kind of general education component that it didn't necessarily fit into a service necessarily line, although it may be integrated within the service. We're talking about some cancer specific knowledge, the disparities, communication, standard guidelines, and I'll go through this relatively quickly so we can talk about it. Cancer knowledge, this is kind of like the basics of cancer, right? This is the medicine part of it in terms of understanding what kind of treatments our patients go through. So everyone that sees neurologic patients or a Parkinson's patient, you want to know about Parkinson's. You want to know about the treatments. So although we are a physiatrist, we still need to be keeping up to date about those next steps going on because the treatments that are happening are affecting what we end up seeing. So assessing the surgeries, I like to look at op reports. It really helps me kind of figure out whether there's any changes versus if they just had this one line. And so understanding where that is to really gauge your impairments. But you have to have that knowledge of the cancer as you're doing your assessment. Disparities, I think this is a really important piece as we're talking about our patients who have varying disabilities as well as financial related concerns and especially cancer care that's changing depending on the patient populations we see. So there's really a lot of challenges that our patients face that I don't want to say other types of diagnoses or people may not, but it is quite unique in the changing dynamic, especially as cancer has changed a little bit more into our chronic disease end for many of our patients that we have to be aware of not just the acuity of what we're seeing, but paying attention and having that long-term foresight. Our communication skills, these are important not just obviously when we see cancer patients, but also all of our patients that we end up seeing. So really important as we kind of gauge through. And from a program building end, obviously this doesn't fit into a service necessarily line, but a lot of this stuff is in terms of skill sets of how we've all developed and I'm hoping as we get more and more people that are out developing their practices we learn more from what works, what doesn't work as the changing dynamics of healthcare, the navigation of the electronic medical record system or health record, integration with the team and the delivery systems. I know whether you're living in a different state, whether the healthcare model has changed, even the systems of academic setting versus community hospital, all of those systems really affect of how we can manage our patients. Are you managing the therapist or all of the therapists are private practice that you kind of just talk to on a half basis or are they under your department? That also makes a difference of how you need to manage your practice. And then really leveraging and understanding community resources are really important. And as I mentioned for all those things above, we really need to gauge of what you can use outside of what's under your umbrella to help people. The standards and guidelines, obviously this is going to be as Eric mentioned with this document, this is kind of a living breathing component because these standards and guidelines are often changing every few years. So basically understanding commission on cancer, the accreditation bodies, this is just a few. This may grow to larger, this may add new people in, but the common ones we all see are the NCCN, ASCO, ACS, American Cancer Society, ONS is the Oncology Nursing Society, which actually pulls out a fair amount of guidelines. It has some power in our cancer community and the ACSM, which a lot of our colleagues have talked about in terms of exercise models and things and guidelines we need to be paying attention to. Outcome measures. So this was a little bit of a, if I recall and you guys may be able to correct me, kind of a iffy area that we kind of talked about as we talked about a living breathing document that what we wanted to do is kind of talk about what's out there and not be prescriptive in how to use things, but really to understand what we need to be assessing. And so we do know about the KPS and the ECOG scores that are out there that have been out there for years and decades, so we have to be aware of how the oncology world uses them, but how we assess things like fatigue and cognition, our function, mobility, strength, and using patient reported outcomes and other functional measures. So how we kind of framed it with this is not necessarily saying you need to use this outcome measure for this, but to be thinking about various outcome measures because this is not us telling people what to do. That's why we didn't really address this implementation and utilization, but maybe as we get more data and we can see what becomes standard and whatnot, we need to develop that. And so I think it's important we think about outcome measures, but we don't necessarily say we have to be married to things just yet as we continue to develop. And then that is, I think, all for our charts right now. We've got another poll coming up. respond in the chat through the app or online as well if they want to add in some of these letters through here. And the next one, one of my favorite types of polls, what words come to mind as you reflect on the utility of the curriculum? Martin, yeah. This is the first time I've been involved in a talk with this word thing, and I really like it. And so, are you ready to pass it over to Sean? Okay. The AAPMNR has foolishly trusted me with their iPad. So if you see Megan or other staff sweating over there, I'm going to try not to do anything to this. But on this iPad, your questions will appear if you want to type them in the app. If you don't have the app and you have a question, we do have microphones, but we're trying to do this through the app so the folks watching virtually can participate, but also hear the question. So I will be grilling these four. So the first question comes from Chris Custodio, hoping we could comment about adjusting the living curriculum document given the advent of telemedicine. Does anyone have a thought on that? How can we leverage this? How can we leverage telemedicine and virtual care to adjust this living document? So I guess there's a few ways of looking at the question. One is incorporating telemedicine. Yeah, so that would be area of practice, it could fall within inpatient or outpatient, mainly outpatient. And also communication, that category. It could be. You know, it's kind of interesting, because how many residency programs are training residents in telemedicine, right? And so how much of this is core versus cancer-specific and that sort of thing. I think some of that has to evolve. Maybe it also becomes part of that special consideration section when we're thinking about the different areas. If you were doing telemedicine or you were evaluating a patient, you know, what knowledge should you have? What skills should you have in terms of the physical exam component, the history-taking component? So even though it may not be something that every program is doing, just acknowledging it in that area where we can kind of touch on it, because I feel like it encompasses a lot of it. Okay, other questions. Is this curriculum ultimately designed to result in board certification for fellows slash current attendings? Mary? Oh, you did that. At this point, no. It's really meant as a tool to help us get better and more consistent in, you know, dealing with our residents and fellows or really to be used by anyone who wants to, you know, some direction in improving knowledge. So it is a good substrate of, you know, potential competencies and, you know, as the field works toward possible ACGME accreditation, the fact that this exists is a very good stepping stone, but it's not intended nor really could it be used in terms of, okay, this must be mastered to pass a board exam. It's not that level of documentation. So, yeah, we didn't present the whole document because it is a lot of hmm and burdensome and large, but if you end up looking at it, some of those pieces are making sure you understand how to do a comprehensive neurologic exam, right? And so that's not necessarily something we'd frame from that standpoint. So it's a little bit more of a structure potentially to start thinking about what we entail and what we identify as a group, not necessarily a specific knowledge base, like these are the five things you need to know about this or red flags. We may talk generally about that, but it wasn't like listing those out, because that would be another textbook. So we really wanted to give the structure and the outline and not talk about, you know, specific maneuvers or those sort of things. So it could be a working off point, but I don't think that's what we wanted to do. And so much of it is really at judgment call level now, especially with assigning the levels. Like Lisa mentioned, I did use this as a guide the last time our didactic module came around for our residents. And when we were going through this for breast cancer, for example, in the first iteration, we had a preponderance of items at the resident expectation level. Then we went back and looked at it. It's like, no, this is more specialized. Residents wouldn't necessarily know all these ins and outs of lymphedema and musculoskeletal issues and breast cancer. And Eric does some types of injections that I was barely even familiar with. So we switched a lot of it to more specialized expertise. But then I found as I was preparing the lecture, I was like, this isn't specialized, but I want my residents to know about this and they're going to see breast cancer patients and they think injections are really cool and this might be a hook for them to know about some of these injections. So just because something isn't specialized and maybe we don't expect residents to know it doesn't mean you can't bring it to that level if you think, you know, it's valuable. Yeah, and piggybacking on that last question, we have, you know, Evelyn Chin coming live from Seattle says, Is there a goal of using this curriculum when guiding ACGME accreditation? Phil Chang said, Any thoughts or work towards a set of standards that would inform ACGME accreditation? And it's no secret, you know, there's been public town halls about cancer re-medicine as an ACGME accredited fellowship and that's something that is being considered slash pursued and part of the process would be to tell the ACGME, this is what we are and this is sort of how we are trained and how we would train and there's been this iterative, you know, process to come to those conclusions. It's not just a few kind of rogue agents, you know, telling that to the ACGME. So I think this all helps towards that goal, but as that would go further it would have to be refined a lot more. There would have to be board questions and it would have to be official to that end. A few more questions really quick. So I have, as a pediatric rehab physician from David Pruitt, who does a fair amount of cancer rehab, I understand the hesitancy in including PEDS cancer in the current document. My only concern is not incorporating PEDS cancer survivorship issues, which can be very different due to different treatment protocols, within 85% survivorship of pediatric cancers altogether. Adult physiatrists would greatly benefit from being knowledgeable about most frequent concerns of pediatric cancer survivors. Anything to add to that? I think that's pretty unassailable. So I apologize if I went through quickly. We do have a pediatric section on there. It probably was not as robust as our probably pediatric colleagues would probably build up. I think we probably... That would be one piece to actually gain input on. I think we've talked about at our networking meeting, we talk about the AYA group as well, that transitional, as we talk about adults as well. I think overall as a specialty we've probably lacked our involvement in some of these aspects. So I think we've recently gotten our pediatric subgroup involved in our kind of community and hopefully starting to link that together, but I think that would be some of the feedback we absolutely would love on the document of more pediatric input and especially that transitional as we talk about teens and young adults. Yeah, and I'd like to especially thank Dr. Pruitt, because I did the first draft of the pediatric section of this and let's just say I very heavily borrowed from a chapter he wrote. So before I call on Jen who's standing, kind of piggybacking on this living document idea, Megan Nelson said, where does the living document reside? Great question. How often will a group of individuals gather to reassess the changes to be made? Another great question. Will that require approval from the Board of Governors to make any change? Great question. And Brian McMichael had a similar question about a process for this modification. Can we speak to that and how this gets updated? So if you go and look at the curriculum overview that's been published this month, there's a link in there. It's curricula.aapmr.org. This is a really cool site to go to because we're not the only ones doing this. You can see the other PM&R BOLD subgroups, the other curriculum that have been published as well. So that's where you can find this. In terms of the modification process, no, I do not believe this is a Board of Governors change. It would really be talking to you guys as the PM&R BOLD co-chairs, Dr. Smith and Dr. Vargo here. So I would think people could just reach out to discuss that. Jen Beaman. We just want to applaud you who all have really unique cancer rehab practices that you're passionate about, putting numbers on something that's exceedingly difficult to do. Thank you. Should have called on Jen way earlier. Thank you, Jen. That was a great comment. Thank you. A few more. Jessica Casey. Are there any resources that may be recommended for residents pursuing cancer rehab as a specialty? It seems general PM&R resources do not go into enough detail, I would agree. Well, some oncology resources go into way too much detail, you know, i.e. outlining common cancer treatment modalities. Yeah, any recommendations for resources beyond this, which is sort of a foundation? I mean, I don't know what the AAPM&R rules are regarding endorsing textbooks, but there is a very large cancer rehabilitation textbook written by someone in this room that is an amazing resource. But there's also other people in this room who have written condensed versions of cancer rehabilitation knowledge that might be, you know, a more digestible starting point for a resident. But I will say, you know, our fellowship directors in cancer rehabilitation got together the other day, and there probably are not enough resources just talking about career development in cancer rehabilitation and what that career path looks like, what fellowships are like, what kind of jobs are out there. So that is definitely something we need to put more work into. And just in terms of the curriculum itself, that was something we really wrestled with, you know, how much educational detail to put in it. And do we just stick with stating what the competencies are, or do we put kind of slide some content in there to give a hint, you know, towards, like, more substance. And it was really hard to know where that line is. So, like, something like, know about tools to evaluate cognitive impairment. And I think in one draft, you know, it was me. I had written something like, know about the, you know, MOCA, and I listed, like, 10 or 12 other cognitive tools. And the rest of these guys were like, what are you doing? You're giving the answers. But, you know, you kind of want to give some guidance towards the answers. This is really about the competencies themselves. But I think as you look at it, it's something that can be learned from, even in the, there's enough detail there that just looking at it is a learning experience, even though it doesn't technically include, you know, a ton of, you know, say, answers to the questions. But we did also think about, like, should we have, you know, references, you know, for the particular items. And, you know, we kind of wrestled with that, but that was just sort of a bridge too far for, that's even more aspirational. So maybe someday we'll get to that. Yeah. And Hannah O. asks, you know, are there, what are the next steps for sharing this with residency directors to guide didactics? And it sounds like we don't know that, I mean, do you want to comment on that? Well, the publication itself, and then, like I mentioned, just earlier today, there was a GME summit where, you know, PM&R residency program directors, some chairs, fellowship directors were invited to kind of socialize the idea of the musculoskeletal sports curricula, as well as the cancer rehab curricula. So that was kind of an initial step to make programs aware of these resources, and there'll be more coming out in the future. Okay. A few more questions. Dr. Chin and others have said, have asked along the lines of what are the next steps or any thoughts to using this to help guide referrals from our colleagues in oncology? Any thoughts on that and what we can do to use this as leverage? I think, I mean, to me that falls mainly with core services and getting the word out about that, because, you know, that's more of a simple... It's still, there's a lot even to that in terms of, you know, communicating, you know, to outside individuals, but I think that more puts it in a nutshell where we can be concise, whereas the curriculum, you know, more of an internal tool. Yeah, and I think the core services document is short enough that you literally can print that out and hand that to a referral source and say, hey, this is what I do. I mean, I think it could be potentially very practically useful. Yeah, just another comment. I mean, I think these documents feel free to use and kind of take bits and pieces from it. I know when I started for this whole idea I think was mentioned what breast cancer started and it's lymphedema. I really... I literally wrote a letter with my name. I'd like sign a name and make it instead of having to go through marketing that listed, hey, these are the things that breast cancer patients may face and I gave a stack to the breast surgeon who didn't really talk to his patients and just said like, go over there. And so they had an idea of what I did even from before. So I made like a little breast cancer core services letter to give to them and that may be something you choose to do. The one thing I think that we've kind of touched on, none of us do everything on this document because you can't and we probably don't have the knowledge or the special, you know, the specialization to do that. So I think for our early career trainees don't get, oh my God, I don't know any of this type. It can be overwhelming even when we look at it. And so some of us may have relative niche practice and we may delve into some of those other aspects. So take bits and pieces of it and kind of utilize that as well. And I think when I've looked at the document, I was like, oh my God, I don't know any of this. And so we need to kind of gauge through that because I don't generally do procedures and things like that. So I like to think I have some knowledge and specialty, but we also have to recognize of where we need to utilize our support and that's, I think, important for program building as we talk about core services as well. Yeah, but I would just add to that, you know, I think the way the curriculum was designed is that it's designed to say we might not do interventional spine procedures or whatever, but we know about it. We know what patients would benefit for an evaluation for that or something else. So we can still be a one-stop shop, a starting point for care, even if we don't do all of those things. I think what was nice and, sorry, Sam kind of touched on it too, is that we all do practice very differently and you can actually look at a subsection. So if there's a specific cancer type that you're interested in or a specific impairment that you're interested in, look at those aspects of this document. What falls under that in terms of core services? Or if it's something that you want to learn more about, what is it under the curriculum that you should really look into? And then use that to build your program. Well, now I've learned about these things. I have whatever certifications. I've learned these skills. And then you can mark it to the oncologist or the surgeons or the radiation oncologist who are treating that specific area. So then you don't necessarily have to be so overwhelmed by the document, but you can actually use those building blocks and those areas that we've all built in different ways and kind of build your own program from that too. Okay, a couple of good comments in the chat. If you have the app that, you know, the Rehab Tumor Board, that gets posted about on PhysForum. If you're a subscriber, could possibly follow this curricular structure. That was from Jess Chang at City of Hope. She comments on the Fellows Journal Club, you know, which residents can join as far as education. Chanel Davidoff asks, could this document be modified into a checklist for current fellows to use as a guide for competencies and objectives throughout the years? It would be helpful. I think that was, that's kind of the intent, right? It's a PDF right now, but we're going, it's, it's not, it's not in its final state right now. We just wanted to have something up, but yeah, it's designed to be more user-friendly. Anything to add about that? Okay, I think I got through all of the questions. Somebody pipe in now if I didn't, otherwise we should be good. Thank you everyone for your attention. This has been a labor of love and, and it's a really a community effort, so glad to see you all here. I hope you have a great rest of your day.

core services component

curriculum

cancer rehabilitation medicine

physiatrists

clinical areas

procedures

resident and fellow training

competencies

wellness

program building

education