Okay, welcome everyone in our cancer rehabilitation member community. I am Leslie Begay. I am current chair of our member community. I'm also an associate professor of PM&R at Hackensack Meridian JFK Johnson Rehabilitation Institute with Rutgers Robert Wood Johnson Medical School and Hackensack Meridian School of Medicine, and I'm also director of our cancer rehabilitation program. Today, I'm happy to introduce, we are going to have an amazing panel of physicians present on different business models of cancer rehabilitation practices as sampling from across the nation. I'm going to let Carolyn tell us some of the guidelines for the session, and then I will happily present each of our different speakers. Thank you so much. So just a few housekeeping notes. The views expressed during the session are those of the individual presenters and participants and do not necessarily reflect the positions of AAPM&R. AAPM&R is committed to maintaining a respectful, inclusive, and safe environment in accordance with our code of conduct and anti-harassment policy available at aapmr.org. All participants are expected to engage professionally and constructively. This activity is being recorded and will be made available in the Academy's online learning portal. An email will be sent after this activity with a link to bring you to the recording and the evaluation. For the best attendee experience during this activity, please mute your microphone when you're not speaking. To ask a question, please use the raise the hand feature and unmute if you're called upon, or use the chat feature to type your question. And time may not permit the panel to field every question. And thanks so much for joining us. Thank you, Carolyn. Okay, so first I'm going to tell everyone who's going to be on our panel today. I'm just going to introduce their names right now. And then before each speaker, I will reintroduce the individual and also give a little bit of background of what type of practice they have and where they're currently practicing. So our presenters today will be Lisa Rupert from Memorial Sloan Kettering Cancer Center, Michael Stubblefield from Kessler and Revital Cancer Rehab Program, Kelsey Lau from MultiCare, and Jessica Chang from City of New Hope. So first, we're going to start with Dr. Michael Stubblefield. Dr. Stubblefield is a Medical Director for Cancer Rehabilitation at Kessler Institute for Rehab, National Medical Director for Select Medical Provider Cancer Rehabilitation Program, and National Medical Director for Complex Medical Rehabilitation for Select Medical's Inpatient Rehabilitation Hospital Division. He is also President of the International Cancer Rehabilitation Foundation, and the former Chief of Cancer Rehabilitation at Memorial Sloan Kettering Cancer Center. He is also the President of the Department of Cardiology at Rutgers New Jersey Medical School. Dr. Stubblefield, if you would like to jump on now and share your screen. Okay. Thank you very much for that, Leslie. Can you guys see the slides okay and hopefully hear me okay? Yes. Okay. Awesome. So, yeah, 15 minutes is not a lot of time. I've got a few disclosures. The biggest one being the new textbook, third edition, will be coming out in June. Also, June is going to be Cancer Rehabilitation Awareness Month, if you didn't know that, something we're starting with Select Medical and APTA and Revital. So, I just really want to start with a couple of basic things, right? To be profitable, obviously, you just need to generate more revenue than you spend. The problem with that is the whole system is really geared to make it really complicated to fully understand how much money you're bringing in versus how much money you're spending. And that's been kind of a constant theme that I could spend the whole hour talking about. One of the things that you need to really understand is how you spend your unreimbursed time. And I know you guys know this. It's reviewing records, getting prior authorization, filling out disability forms, talking to your colleagues, talking with the family when they call with 20 questions. And that's actually kind of a big problem, right? It's one of the issues that really contributes to physician burnout. And physiatrists really spend more time disproportionate to other groups of physicians, about 18, approaching 20 hours a week. That is a lot of time, especially compared to other specialties. So, another point I want to make before I go into some advice on this, and hopefully we'll have some time for questions, is there's no special billing code for cancer rehabilitation, right? You being the world's top doctor or being a new grad right out of residency doesn't make you any more money. And the billing codes, the E&M codes used are identical to what your surgical colleagues, your oncology colleagues, and everybody else is using. So, it's all the same. So, then why does everybody else seem to make more money? So, the rehabilitation is not bad. And I hope all of you are making at least $300,000 a year. I suspect some of our junior people aren't and others are making more. But the average oncologist is making really 50% more than you. The question is why? Did you ever wonder that? It's the other stuff. It's largely the chemotherapy infusion, which cannot exist, right, without them as sort of the gatekeeper of it. So, in a sense, they're being subsidized for all of these other things. For surgeons, it's a facility fee, right? So, it's the fact that the hospital is making so much money, they have to have a surgeon to make those facility fees to do the surgery. So, that really allows them to generate much more of an income. Some, you know, neurosurgeons are making in excess of seven figures a year doing what they're doing, largely because the facility fees. And they're not, you know, they're busy, but they're not necessarily any busier than you in doing other things. So, you need to look at what you're doing. If you're making $300,000 a year, that's about $150 plus an hour, or $2.50, $2.60 a minute. Now, your assistant who's out pushing your papers and scheduling your patients may only be making $30,000. Maybe they're making $60,000 a year doing what they're doing, which would be actually very well paid if they were making $30 an hour. So, here's the question. Why on earth are you doing stuff? Like, every time I have to log in and check the, you know, for opioids I'm prescribing, check the prescription monitoring program. And that takes me three or five minutes. In the perfect world, you have to ask yourself, why are you doing that if you can have somebody else do it? Why are you grooming the patient? Why are you doing this thing? So, we know that you're going to do some of it, and you can't be busy for the full duration of the day. But you really need to think about what you can offload to other people to really maximize your ability. Because you only make money when you see a patient and generate a report on that patient. That's the only way you make money. Sitting there talking to the family feels good, right? It's good medicine, but you're not necessarily generating revenue on it. So, you really need to work at doing the things that are most important that only you can do, and really try to maximize the other stuff. And it feels like you're, you know, I don't know, you're dumping stuff on people. Dumping it on residents is perfectly fine. Those of you who are residents out there, just, you know, consider it your lot in life for now, because you're already paid for. But if you're in private practice, you really need to be conscious of how you're moving your money. The other sort of primary thing you really need to know, as E&M services really undervalue thinking, right? So, I like to pride myself on taking care of really complicated cancer patients. I get the worst of the worst, the head and neck, the Hodgkin survivors, right? I get patients coming from all over, and no matter how good a note I write, how much time I spend on it, no matter what I do, I get paid the same, right? I can only get paid so much money for it. There is kind of an over and above rate that I've literally never used. So, Medicare penalizes, which means all the other payers penalize complexity over volume. So, being efficient in how you are generating the information you need to do a good evaluation and management of the patient is critical. Supplementing with procedures, I do a lot of Botox and other sort of joint procedures, also very important. Our interventional pain colleagues are basically looking at a little hole and sticking a needle in it all day long, and the ones who are really good are running a mill. They're going from room to room to room. They're doing 30 procedures a day and not doing really much of anything else. Fine, if that's what the patient needs, but that is a good revenue generator, but not necessarily the type of care that patients or residents want to do, but you should consider adding procedures. Value propositions. This is another thing I spend a lot of time with. I've kind of moved into being, you know, I, because of my role at Select Medical and Kessler, it's not really about volume for me, and fortunately, in an academic center, never really have been. But we need to think about our value kind of for the global community. So, improving patients' function and quality of life is great, but also our role in pain management, minimizing opioids, our role in minimizing emergency room visits and hospitalization, getting patients back to work, and most importantly to any payer who's looking at this is the overall cost of care. So, this is something that particularly with my provider program, which I'll talk about in a minute, it's become absolutely critical to getting us in the door at a number of places. It's to really kind of convince people that we have value above and beyond what we would necessarily be billing. So, I'm just going to talk briefly about therapy, because, and let's see if the next slide is better. Right. So, one of my major things, and I kind of chose to talk about the physician side as quickly, is I have 1,000 therapists. It costs millions of dollars and countless hours to develop the program to train them. So, I have over 1,000 therapists working in 26 markets in like 24 states across the country and being profitable as a therapy service. And there's a lot of little rules that you have to understand. One, Medicare doesn't reimburse. If you have a Medicare patient, you're doing lymphedema management, you might as well just get Medicare $10 for the privilege of taking care of that patient. The only way to really make money in therapy, and a lot of the academic centers lose money on their therapy services, is to have one therapist on at least two patients, kind of an orthopedic model, which we are trying to do, and still have super high quality in the cancer center, and make sure that the therapist's ability to document and do everything is as efficient as our ability to document and do everything. So, with this model, we've managed to see over a quarter million patients last year across the country, and with really good feedback from our patients and anybody else who's working with us. So, a couple of key points. We are no different from any other medical specialty or rehabilitation specialty in terms of how we build. So, you need to be conscious about that being profitable foundation. There's nothing immoral about making a profit. That's the only way you can keep your doors open and the only way you can give the patients the service they need. We have no special billing codes. Ours are the same as everybody's. We just have to use them properly. You really need to be valuable above and beyond how you bill. Everybody needs to work at the top of their license. That means your assistants need to be, you know, really earning their $2.50 an hour or $5 an hour so that you can make the whole service run better. You need to, you know, add procedures. That's why, you know, pediatrics doesn't make a ton of money if there's not a lot of procedures. Outpatient therapy services are going to grow substantially over time. I think they're really kind of a driver of cancer rehabilitation, and I think that's a good thing. They do much better with us, and we are incapable of really getting good outcomes without therapy service. So I didn't talk really about inpatients very much, but that's a whole other thing. I'm going to be writing an article for Current Physical Medicine and Rehab Reports on how the government is basically adversely affecting our patients with their sort of draconian rules. And you need to really understand the financial implications of, you know, providing cancer treatment to patients who are in the hospital. And I think that's it. That's my contact information. I'm happy to field questions or comments or anything for many of you. And I think I did that in about 12 minutes, leaving just a couple of minutes for questions if there are any. That's great. Thank you, Dr. Stubblefield. I think if it's okay with you, we're going to hold the questions until the end and make sure we can get all the speakers through. But if anyone has any questions for Dr. Stubblefield, and thank you for presenting on, you know, cost of care, different challenges, and financial sustainability for cancer rehabilitation, we'll definitely hold on to them and address them at the end. Okay, so our next speaker is going to be Dr. Kelsey Lau. Dr. Lau is going to present on hospital-based and hybrid models, talk about referral networks, administrative considerations, and integration. She completed her PM&R residency at UTSF in Dallas, a fellowship at the University of Michigan, and is now a cancer rehabilitation physician at MultiCare, a nonprofit healthcare system serving the Pacific Northwest. She works in Gig Harbor and Tacoma, Washington, within the pain department, focusing on building the cancer rehabilitation program there in partnership with MultiCare Cancer Institute. Dr. Lau, if you have slides to share, or you can do that now. Okay, great. Okay. Can you see my slides and hear me okay? Yes. Yes. Okay, let me just get my screen sorted. Okay. There we go. Okay, so I have three main slides that I want to talk about today. To give you a little bit of a background of where I am, so I do work in the pain department. I am the first cancer rehab physician to come to MultiCare, and I am also a new grad, so learning a lot at the same time trying to build a program. So in terms of integration with hospital systems, it's important to get a feel for the lay of the land. What does that essentially mean? So the biggest question by far, which I'm sure most of you know before anything else, is do you have the buy-in from the oncology teams? Do they support your vision, and are they willing to help sell your brand? Do they actually understand what you're trying to do as a cancer rehab physician? And then also, are they interested in building more supportive care services to integrate you? And ultimately, I think this has to do with what you can provide, but it also has to do with timing and finances. So what I did when I came into the role, and I'm just going to go through questions that I asked myself and steps that I took. So what departments are there currently in place when you're initially looking for jobs that you could become a cancer rehab physician? Is it a PM&R department? Is it a pain department? Is it another department? Is it the Cancer Institute? When I was going through my experience, the PM&R department did not have a position open. The pain department did. Part of my interview process included some oncologists, which I really appreciated, and had their buy-in up front, which I think made my part easier. And so just knowing the lay of the land, if there is a PM&R department, you want to be aware of what their services are so you don't step on any toes when you're walking into your role and trying to build a program. And then also knowing what services are already integrated that we need to be successful. So is there cancer rehab, physical therapists, occupational therapists, speech therapists already integrated? Do they have psych onc in place, lymphedema specialists? Do they have a palliative care department, interventional pain? What does that look like? What I have learned in the last six to eight months is the academic setting is very different than the community setting. And I have hit some roadblocks that I didn't necessarily anticipate. So just something to think about. And then when you think about your job and your vision, do you want to do outpatient clinic? Do you want to do inpatient consults? If there's an IPR, do you also want to do some in-house management? How does that set up with your schedule? If you want to do both consults and clinic, what does that look like, especially if you're the only one that's doing inpatient consults? How does the inpatient team rely on you? And do you ask to only have consults placed one day a week? And what does that relationship look like? That's something that I haven't done, but I have considered. I just haven't gotten that far. And I think at the end of the day, when you think about integrating, it's really important to know the department that you're working under, what their goals are, where your paycheck is coming from and do your goals align with their vision of what they hope for you as well. In terms of referral networks, so prior to starting or building your program, it's important to understand where the referrals are coming from. Prior to me starting my job, most of the referrals were coming from PCPs for the pain department. And so you want to think about how can you sell your services to the oncology teams? How can you best essentially advertise yourself? And what you have to offer. Really know who your cheerleaders are. My biggest support has been the medical director of supportive care services, and she's a medical oncologist. And she has really opened a lot of doors for me, which I'm incredibly grateful for. And I do think that timing was also part of this. And so once I started my job, I gave a lot of different presentations to different groups, med-onc, rad-onc, just educating and sharing what services I provide. She also got me integrated with daily tumor boards. And so you know, my name and my face got out there. So people started recognizing me, which helped also with referrals. And then I also thought it would be important to contact the director of the PM&R department to establish a partnership there. To know how that department works, what the current setup is, and how I can work with them as well. So I also thought about, because through fellowship, the interventional pain team that I worked with was very helpful for managing pain. And this is one of the roadblocks that I anticipated or didn't anticipate, but I have come across actually, in the community setting. And so the, at least in this area that I work in, the interventional pain docs don't like to or are open to treating cancer patients as willingly as I have experienced in the academic setting, which is unfortunate. And so it's been a challenge for me for a patient that could really benefit to find a referral source that I can refer to for interventional pain procedures. It's a lot of legwork. And I think trying to find someone who you can develop a relationship with, that you can share patients with, is also helpful to build up your referrals. And then I also met with the business side of MultiCare, Cancer Institute, the AVPs, to map out essentially what my services are, what steps I can do to build my brand and help the cancer patients. And so when I talk about timing, I think a big part of this was that the Medical Director of Supportive Care Services is looking to build up the program. And so I was able to be named the Cancer Rehab Puget Sound Physician Representative for the Cancer Institute. She asked me to sit on and participate on the Survivorship Committee, the Breast Cancer Leadership Team, and then also the Commission on Cancer Accreditation Committee. Which I'm really grateful for. And then my last slide, in terms of administrative considerations. And so I think it's important to know the dynamic that you're walking into for, let's say, outpatient clinic. Since I don't practice under the PM&R department, your immediate support network in clinic. So who is helping you with the paperwork? Is it your medical assistant? Is it your nurse? And do they support and understand your goals in clinic for patient care? Treating cancer patients, in my experience, is different than treating chronic pain patients. And so it's important to have that support in clinic for day-to-day paperwork. Communication, ease of communication in terms of whether it's EPIC or a different system. Being able to contact the oncology teams to build up trust. And then just to talk about patient cases, concerns that you have given the medical complexities. In terms of referrals, do you want to review your own referrals? And if so, what does that look like? That is an extra burden, extra time. How do you tackle that? How do you address this with your referral coordinators in terms of flagging more urgent referrals? It's a lot about communicating. And then in terms of who you refer to, and just like administrative wise, you need to also make sure that where you're sending your patients, whether it's to PT, OT, speech, whoever it may be, that you trust them. You trust their work. The patients are coming back and they're happy with their progress. You're seeing functional progress being made. And so really being integrated from a community standpoint is important. I have learned that different PT clinics in the community have different amounts of time spent with patients, different devices, and different outcomes. And so to be successful for us, it's important you know where you're referring to. And then just meeting the teams in terms of showing your face, really putting in the time to build your network is important because that investment will come back to you. In terms of difficulties encountered, and so, you know, I've been in this position for about the last seven, eight months. Some of the challenges that I've encountered have specifically been neuropsych referrals in the community. And so the way the hospital system is set up with what we have right now is there is one neuropsychologist who is housed in the neurology department who only accepts referrals from neurologists and is scheduling out 10 months. And so I've had to do my own legwork to figure out who to refer to externally. And then also EMG referrals. Again, it's only the neurology department that does it and they're scheduling out over six months. So as I'm sure everyone knows, this is not just a problem I'm having here in the northwest. This is, you know, a healthcare system problem. But it's making sure that when appropriate, you know, you're going the extra mile to reach out to other providers and asking if possible to fit them in as soon as possible if needed. And I think as I close, I just want to say from my experience that I've learned so far, it's really about what your vision is and your goals and then taking the right steps to navigate the complexities and ultimately be successful. That's all I have. Thank you, Dr. Lau. That was great. Really enjoyed hearing your transition from academic to community. And also while starting your own, you know, program and the challenges that you've had so far. So I wish you good luck with the continued growth in that area. Well, like I announced before, in case people jumped on, we'll hold questions till the very end. So please take a note if you have any questions. I'm going to continue on to our next speaker who is Dr. Jessica Chang. She's going to speak about the role of interventional procedures in a cancer rehabilitation practice as well as potentially billing strategies and the clinical applications of oncology rehabilitation. Dr. Chang is Assistant Clinical Professor in the Department of Supportive Care Medicine and Medical Director of PM&R at the City of Hope in Orange County. And City of Hope Orange County Lenore Foundation Cancer Center. Dr. Chang, whenever you're ready. Hi, everyone. Thanks so much for having me. And so this was all, I will skip this since Leslie just mentioned all of this. So let's dive right in. I have no disclosures. I wish I had some. Here's the overview of what I will talk about. One is my unique practice setting and then the role of procedure, the why and what. And then lastly, building a procedure practice, some logistics and some big picture tips. And so I've been out of fellowship almost three years now. And this has been quite an adventure. So my practice setting is purely outpatient. I do include in-clinic procedures. I will not say that I focus on procedures or tell everyone about procedures specifically, but I do do them. And I am in a cancer center. So it's not part of a university system. So what you see here are the actual equipment I have. Sonosite LX that I asked for before I signed my contract. And a portable EMG stem device and an injection cart are my main tools. And my practice setting is pretty unique. PMNR is a startup within a startup is how I like to put it. So you may have heard of City of Hope. It's based in Dorte, Pasadena, more close to the mountains. That's the original location. But the site where I'm at is meant to be a second main site. And it opened in August 2022. I start at the end of August 2022. I started at the beginning of September 2022. So the picture you see above there is the original crew. So that includes radiation, general med onc, some specialized heme and onc in terms of supportive care medicine, which I'm part of. It's me and integrative oncology there. That's it. And so with this setting, there is a natural openness to new workflows. The whole concept was to do something different and do things better. And so that was really quite a blessing to set up a practice because people were open to new referral patterns. Now the picture you see below is the hospital that is being actively built and it will be completed by the end of this year. And so as you can tell, there are limited adjacent specialties, meaning no interventional pain to start with, no ortho. There wasn't palliative, no neurology, no rheumatology. And so the field was wide open for PMNR and for procedures. There is one guy here, IR, which was the only other kind of pain type of proceduralist. So it's good to have that connection there. And because of this context of everything being a startup, their change was basically a constant and being aware of what that meant for building not only a PMNR practice, but also a procedure practice in this setting. It has been a great learning opportunity. So why do procedures? I cannot emphasize the words performance status enough. I know we like to talk about function and activity. I find the phrase performance status really hits the oncologists really well. So I frame everything as improving performance status, aka using procedures to help with participation in exercise, in physical therapy, in prehabilitation. We know that procedures can be opiate sparing. What I've learned in my time as an attending is that actually NSAIDs and Tylenol, these common over-the-counter pain medications, one, a lot of patients are on glycoagulation, and a lot of people are concerned about their liver function. They're also on chemotherapy. They have a lot of comorbidities. And so it's not just opiate sparing. It's all the other pain medication sparing. It spares all the other pain medications, and that is a pretty important point to many of my patients. We know that procedures can be diagnostic and therapeutic. And this point is particularly important within the cancer center. A lot of times patients show up with, oh, this hurts, this neck pain, this neck area, shoulder area hurts so much. And you know, after I tell them about myofascial pain or trigger point, I do the trigger point injection and tell them, yeah, well, it's not cancer. Or even without the injection, you know, on their mind is, is it cancer? Is my cancer back? And they're so stressed from that that they're tightening up on their muscles. They're creating this trigger point. And so even in a non-procedural practice, as PMNR, if we understand procedures, we understand myofascial pain, something as simple as that can be so therapeutic for the patient. And so procedures in the clinic setting is very low risk compared to everything else going on in cancer or pain, pain procedures, like actual procedures, and I would say it's very high value. This goes kind of contrary to what Dr. Stubblefield was saying, but in my experience, there's this big misconception that procedures are increased productivity. Actually, it's like less than a third productive compared to a regular E&M follow-up visit for the time I spend on, say, a trigger point injection. And so, but I think it is a huge differentiator for my practice, and one of the key differentiators, and I'd like to encourage everyone in PMNR, whether doing procedures or not doing procedures, that our physical exam, our MSK neurophysical exam skills, are so important, if not to do the procedures ourselves, but at least to direct people to the appropriate procedures. So many times patients have already seen a number of pain and orthopedic doctors locally, and then I'm doing the physical exam, and they're like, oh, no one's ever done this before, and I'm kind of surprised, because I wouldn't pride myself to say I have the best physical exam skills. So I think this is a huge advantage that us as physiatrists have in helping with doing procedures in procedure navigation. I'd like to emphasize procedures as a mechanism to enable timely cancer treatment, particularly in the preventive phase. So here you have the DITS, preventive, restorative, supportive, palliative phases of cancer rehab, and so I see procedures as highest value in the preventive or prehabilitation phase. For example, I have a patient who has a lot of baseline orthopedic issues as a high-level gymnast, got a breast cancer diagnosis, and she wanted her orthopedic care in the same place as her cancer care. She was told that I only take patients who have a primary oncologist internally, so she was like, I will switch my oncologist then, just so she could see me, and get trigger point injections and knee injections that she was getting already. And so that really spoke loudly to me, and it's also important that in that space for the procedures to be timely, because the whole goal of that prehab period before cancer treatment or during cancer treatment is to help people be able to get the benefits of exercise in order to get through their cancer treatment and recover from their cancer treatment better. So the timeliness of procedures can be quite a logistical challenge, but a worthy challenge to face in your practice. One of the common examples I like to give is that a lot of times after breast surgery, people get frozen shoulder before they can get to radiation therapy. In that picture, you can see a position, basically arms have to be overhead, and due to people wanting to protect the area or being scared to move, they often get frozen shoulder. And so that's one of the time-sensitive procedures that I would do. Sometimes it's not actually adhesive capsulitis, sometimes it's a bicep tendonitis or a rotator cuff tendon issue, and getting those injections in a timely fashion to help our radiation oncologist do the planning is extremely high value for my practice. As for the restorative aspect, I had a patient who was a early breast cancer, status post-treatment, and all the oncology notes for like a year, a long time, was saying that she was having psychosomatic weakness and she was limping around. And this is someone who was a very high level, I think in the pharmacy world, very high level person, career person, and she was limping around. And when I saw her, I just, you know, did a physical exam. She had a gluteal trigger point. I did the, I did a trigger point injection, and she went back to work the next week. And mind you, she was telling me that she contacted 18 doctors, went to the ED, got hit with opiates, nothing is helping, and it was just a trigger point injection that she needed. And that was more in the restorative phase. So procedures, even if they're not high productivity, they're like negative productivity value for me. But the value, the clinical value is so high for patients. And then on the supportive palliative end for procedures, I may be a little more lenient on the rehab therapy side and just weigh the benefits of quality of life and function for the patient more. Because like I said earlier, our procedures are quite low risk. And I often tell people that the needle is much smaller than your blood draw needles. So that gives you some kind of perspective of, or helps patients have some perspective when they're really anxious about any procedure. And so I think the difference, so we always want to know what's the difference between what we offer versus a trigger point injection by the interventional pain department or family medicine or other providers. Because we're always, I think Kelsey's talked about not stepping on toes, pumen are overlapped with everybody. And so I think the main differentiator of cancer physiatry is that we can help with navigating the whole spectrum of interdisciplinary pain management, whether or not we do the procedures ourselves, our education and experience is broad, and we can help people navigate where to go next. So what procedures? So a lot of this is, are things that I believe people already know here. This is a QL trigger point referral pattern, because I had another patient that went to the ED because of a QL trigger point pain that she was crying about in clinic. And she only needed one injection too. Those are not all trigger point injections, obviously, but for these people, it made such a big difference. So trigger point injection is the most common injection that I do, and the lowest productivity. And so streamlining that as much as possible is something that I'm actively working on. I do peripheral joint injections, I do certain nerve blocks, I do Botox as well, particularly for after head and neck cancer and after breast cancer treatment. And there's actually a multi-site trial that Dr. Oza from Emory's spearheading that will be starting soon on Botox for these populations. And that is something that is unique to cancer physiatry that I don't see my neurology or interventional pain colleagues offering. These procedures are not procedures that I do, but I have been, because of the startup scenario, I have been in the position of directing people towards IR. When IR was the only one out, now we have interventional pain also. So between interventional pain and IR, they cover the axial injections, the sympathetic blocks, and some of the advanced procedures. But as PMNR, we can be in spaces like supportive care medicine, which IR may not typically be in that space, and so we can suggest or direct people towards advanced procedures. So this is kind of the boring stuff that takes a lot of time, building a procedure practice. There are so many logistics. It's like an onion, that's such an overused analogy. But when you think you've gotten through 10 layers, there might be 10 or 20 or 30 or 40 more. Let's put it that way. So determining what procedures you want to do, what kind of guidance is available or that you can get is important. And it doesn't have to be concrete. Mine isn't concrete. It kind of depends on what shows up in clinic, because we have the capacity to learn and grow our skills. Understanding the clinic leadership. So I put space. Where's the procedure going to be done? Who's available to help you, the personnel? And what is their scope? Can they draw the medication? Are they allowed to get the medication from the PICS? This has been quite a learning adventure, I would say, is understanding that there are so many roles and nuances to that. And that will basically dictate how your workflow can be. So building relationships with the clinic leadership is incredibly important. Let me speed this up a little bit. So and then the clinic staff, who is available, the clinic guide. I developed the clinic guide because we had a lot of clinic staff turnover with it being a startup and growing. The cancer center is growing way faster than anticipated, doing dry runs, debriefing how the procedure went with the clinic staff afterwards. It's something I'm recently learning is extremely important. How you want your schedule or your clinic template. Is it possible to have a procedure clinic or does it need to be interspersed due to logistical issues? How do we optimize the timing, the timeliness of scheduling procedures, wait lists, things like that. Pharmacy plays an important role. That's the PICS. There are rules. Let's put it that way. Building and coding. We have builders and coders. I meet with them. They say I'm doing well. They just run things by them. They tell me when I'm not coding right. But that hasn't happened so much. I've had like one peer to peer where they actually said they want spasticity instead of dystonia for the Botox. Usually, it's the other way around to get the Botox approved, but I haven't had much issues there. Insurance authorization can take time and that might mess up the schedule, but that's something to be aware of and to try to understand. Some of the big picture points is that because of all the scope overlaps with different specialties, I think it's incredibly important to build relationships. I built relationships with neurology and interventional pain, the ones that were not local, the ones at City of Hope at the other site, and try to support each other's practices. There's ways to grow skills, all these resources you hear there. Many people on here have been my resources to help learn collaborative specialties. I was building my ultrasound skills and still building them. I had IR with me at my first use of the ultrasound because he offered, and then the ultrasound techs wanted to learn MSK ultrasound, so we'd get together once in a while. We have Anastasia that does regional blocks, and he's happy to join in on any blocks that he already does for guidance, teaching, and support. That's part of how I've been able to grow my skills, even though I did not have another PMR person to work with. Then just honestly discussing with patients where I'm at with this and that I have a conservative approach. The last pearls I wanted to give is that being patient, persistent, proactive, prudent, prudent on what's going on in the big scheme of things, that cancer is the focus and not orthopedic issues. Having that perspective has been really crucial as I build my practice. This is the take-home summary of all the things I mentioned earlier. Thank you. That's my contact information. Please reach out for anything. I am going to give birth any time, about 39 weeks, so that's what that avocado is for. This link is new as of today for our job posting. We're recruiting one outpatient position with interviewing views starting in July and August. I'd be happy to have someone join me. Thank you. Thank you, Dr. Cheng. I am so glad that you were able to be with us today, and I wish you good luck with everything. Thank you so much for taking the time and sharing. I really love your startup within a startup analogy and just how you had to start everything from scratch, and also kind of stressing how talking about interventional procedures, all different types can spare patients from other analgesics or help them with the rest of their treatment plans. Lastly, the focus on the physical exam. I have had patients also who have stressed to me how I've given them the most detailed physical exam that they've had, which is surprising, but I definitely think is a value that we can add, so thank you so much. Anybody who has questions, please hold on to them to the end. We will now be going to our last panelist, who I believe I saw jump on, Dr. Lisa Rupert. Sorry for being late. No, no, no. Perfect timing. I'm just going to introduce you briefly and then let you go. She is the Program Director for Cancer Rehabilitation Medicine Fellowship and an Associate Physiatrist in the Department of Neurology and Rehabilitation Medicine Service at Memorial Sloan Kettering Cancer Center, Associate Clinical Professor in the Department of Rehabilitation Medicine at Weill Cornell Medicine. In addition to cancer rehabilitation, Dr. Rupert also specializes in spinal cord injury medicine, so this is very exciting, and she's going to present about some of her work in an academic-based cancer practice, the structure of it, opportunities for physiatrists, and other related areas. So, Dr. Rupert, take it away. Perfect, thank you. So, I just want to start by saying I actually don't have any disclosures related to this presentation. On the website, it says that I have a conflict with ipsin. I do have an educational role at Aspen Medical in terms of bracing, so I think there might have been some confusion there, but again, nothing in terms of this presentation. I just wanted to clarify that. I think all of us have an idea about academic medical centers thanks to our medical school training, our residency training, our fellowships, but I think as attendings, we really learn that navigating academic medicine is more than that, and there's probably a lot of layers that we didn't know about, so I want to just present some of those here today and just the idea of how to navigate through them. I think when we all think about academic medical centers, we think of the three pillars, so the idea about patient care, research, and education, and how they really all feed into each other and how they all drive each other, and this is, you know, not just in the idea that, you know, research drives education, which improves our patient care, but how patient care and what we're doing and what we're being reimbursed for actually drives the research, which drives the education, and sometimes it even goes in reverse. Memorial has taken an approach to this idea of the pillars of academic medicine, and it's actually embedded throughout our mission, not only the mission of our institution, but also the mission of our fellowship program, so we have the arrow pointing upwards, forever upwards, and the idea that clinical care, education, and research will drive that, so I want to kind of dive into what does this actually look like in terms of structure and funding and the job roles that we can have in an academic center and also how can we advance our careers here, really keeping those pillars in mind. So, we all know an academic medical center as an accredited degree-granting institution of higher education, and so what that actually means is that this medical center consists of a medical school, one or more other health professional schools, and owned or affiliated relationships with a teaching hospital, health system, or other organized health provider, and why is this important? Because when you are hired in an academic medical center, you really want to know where you're hired, so what piece of it and what is your role within that and what is, you know, the priorities of where you will be, and what does that mean in terms of where you'll be housed in departments or who you'll be reporting to? There are two prototypical models for academic medical centers. The first is the fully integrated model, and this is where the academic, clinical, and research operations report to one person and one board of directors, so if you really think about it, oftentimes it's actually the medical school that's driving the overall vision, and really everything that we're doing is going to relate back to that, and if you also think about this idea that we're all reporting to one person ultimately in one board of directors, you really have to think about what that means in terms of your autonomy and what that means in terms of programs that you would like to build. There's also the split or a splintered model. This is probably where a good majority of academic medical centers are currently living, although there are still, you know, there are some that are also fully integrated, so it's important to know what yours is, but in a split model, you have academic and clinical health system operations managed by two or more individuals, and that those actually report up to two different board of directors, and oftentimes this is the medical school operates as one entity and the affiliated teaching hospital operates as another, and it's interesting because historically, trends might cycle, oftentimes related to reimbursement, but there's other things that drive it as well. When we're thinking about political history of an institution, when we're thinking about the overall economy, we're actually thinking about the broader political environment as well and what that means in terms of different funding. So, in addition to knowing what the academic medical center looks like, you also want to know about its leadership structure, and I think we always think about this hierarchical idea in medicine, and I think that's probably because we're all taught that medicine is somewhat hierarchical, but there are other models as well. So, the hierarchical structure is really what you'll see more in large hospitals, large health systems that are spread over multiple buildings, multiple locations, and so what happens is you have the support services, the diagnostic services, the therapeutic services, informational services, and they're all going to report to leaders. So, if you think about the diagnostic services, here we're talking about all the various departments in terms of clinical care, right? So, where are you living? Is there a department of rehab medicine, or is rehab medicine a service within another department? Will you be in a cancer center where perhaps you might be housed in a different department, and that department chair may then report up to a chief medical officer, who then will report up to potentially a hospital president or a hospital CEO, who then presents up to the actual board, and this is important to understand because it's the board that's going to set the priorities, and it was once said to me that we all serve at the pleasure of the board, right? So, they're going to set the agenda. They're really going to say what it is that the priorities of the hospital are, and we have to learn to navigate within that, and we also want to make sure that our personal mission is aligned with our service or our division or our department's mission, and that that's going to align with the overall hospital mission, and so as you're program building, it's really important, especially when you're presenting a new idea or wanting to build a new program, how does that align? Who are you reporting to? Who does that person then report to? So, you want to understand that, and these hierarchical structures, again, there's going to be a little less in terms of autonomy, and you're also going to find that decisions happen and are made really slowly, and change may happen really slowly. The next structure is actually the matrix structure, so this is a little bit different. Oftentimes, you'll see it in highly specialized clinics. You might see it in research hospitals. There's a lot more in terms of interdepartmental collaborations, so this is where you may report to more than one person or multiple people within different departments report to an individual person who then reports on up, so there's a lot of mixing that does happen here, so it's important to know who you would report to, but at the same time, this actually does give a little bit more freedom in terms of decision making and gets more ideas together. It also may mean that decisions happen a little bit faster. The final structure is actually a flat structure, and this is what you may see in really small hospitals, and this is where every individual person actually reports up to one, and so this is going to be where the decisions happen the fastest. It's also going to be probably where there's the most autonomy in terms of the things that you're doing and how you want to build your various programs. In addition to the hierarchy and where you're going to be living, it's also really important to think about funding, and, you know, I know you've heard about various models of it, but it's important to know where your salary is going to come from, and that means from your clinical care, and it also means from your non-clinical care, so how are you going to essentially pay yourself or justify the salary that you're making, and also how are you going to justify any other types of projects that you may be interested in doing, and how is the global hospital itself funded, and so the primary driver for academic medical centers is actually patient care, and this is oftentimes when you're wanting to build a program where you can actually sell quite a bit, and so when we think of patient care, we have to think of two things. We think of the volume of patients, the services provided, and how that equals our patient revenue, and so volume is actually divided into the number of patients who need care and then the patient's decision on where to go, and so how do these patients decide this? Oftentimes, it's by the services that an institution provides, inpatient care, outpatient care, surgeries, diagnostic testing, any kind of specialty services, so thinking about us in terms of cancer rehab or the procedures that we might be doing. What is it that we can offer that really makes people want to come to our institution for care? What makes us different? And the number of patients who decide to come here, obviously, is then going to drive in terms of volume, and that's going to impact that net patient revenue, so it's going to be those charges that we can deliver, how complex the care is or how long we're spending with patients, how accurately we're doing in terms of our billing. As you heard sometimes, it's in terms of coding or how we're coding for visits. The next thing that's going to impact this patient revenue is really the payers, so you have your private insurance, your government entities' self-pay in terms of patients, and also charity, so where is the money coming from? How are contracts negotiated with the private insurance companies and with these government entities in terms of how much are we actually going to collect? How much are we discounting to have these patients come here? And this is part of what we call the hospital write-off. So when we're thinking about those contractual discount negotiations and also bad debt. So what about those patients who can't pay or the idea that they have copays, they're not doing it, they're not paying that bill. And that has to go into that as well. And so when hospitals are really looking at that, it's part of what they're looking at in terms of our billing and how we're justifying in terms of our charges. You actually can see your gross and you can see your net and they'll show you what that difference is. You can also see how your salary is then broken down to help with hospital overhead, to help with any kind of research and development and to help with any other things that might be important to the hospital and then how much is actually left in terms of your net collections. And where that's important is how are you paid? Are you an RN and RVU model? Do you have a set salary? Do you have a base salary plus an addition that might come from a practice model? So really understanding those things. And when you're thinking about building your program, taking all of that into account. In addition to funding from the patient care, we think about the education programs that we have. So we think about the residency programs. We think about the medical students who are spending time with us. We think about our fellowship programs. And the primary funding source for this is the US government, the taxpayers and how much we're getting for the residents that we have. But we all know that doesn't cover all of their costs. And so we also think about where else it's coming from. So you may be part of an affiliated hospital that doesn't have a residency program, but the medical school and the residency program that you're affiliated with, you may actually give them salary support to have their residents come to you. And so when you're thinking about where we're spending our money and how we're supporting or how that money is funneling between different institutions, it's important to remember that. It's also important to remember that if you're trying to grow education programs as to how many fellows can you justify, how many residents can you justify and where are you going to get that money from? In addition to those sources, there are endowed fellows and there are endowed positions in different training programs. So we have donors who have paid on into that. And that also is a way to think about programs that we may wanna build, especially in terms of any kind of fellowship if that's a direction that you wanna move in. And the last is research. And when you're thinking about it, again, I said, we're thinking about patient care and how that's driving it. And obviously it's the research that really advances care and that makes patients wanna come and it's also helping our patients live longer, which for us in cancer rehab is important because it gives us even more of a role to play during their continuum of care. But where in addition is that funding coming from? Thinking about grants that we might be applying for both through the NIH and private foundations. And here is one where how does political climate potentially impact the different funding that's happening? And are you someone whose salary may in part be part of a grant? And what does that mean if that changes? We might have pharmaceutical contracts that help drive our research as well and thinking about different kind of donors and endowment. And so when you're really thinking about all of this and these are all things that I think are important to think about because you really wanna know who your audience is when you're starting out new and you're wanting to build a program. But even if you've been in a place and you kind of have a sense that there's something I can do here or there's something different that I can do here, you wanna take that into account. The other thing that you wanna know, especially when it comes to the structure is where are you housed? So are you part of a bigger rehab department where cancer rehab is a subspecialty or a unique like we are at Sloan Kettering where we've essentially retrofitted a rehab department into a cancer hospital where we have the opportunity. I get to practice spinal cord injury medicine at Sloan Kettering. We have a provider who can practice brain. We have providers who can practice peds. We have musculoskeletal providers and we actually have cancer rehab trained providers as well. And we all play a role. And so it's really understanding the department that you're going to be in. And it's also understanding that perhaps you might have a dual appointment. So you might fit in two different areas. So you might be on a rehab service and also appointed in peds. You may find that you don't have a dual appointment but your salary gets supported by different departments because of resources and services that you could provide to patients that they're taking care of. And that helps in a way because you really wanna show your worth and you really wanna make sure that you have other providers who are willing to step up and say, we need this person and we're willing to support. You also wanna understand what services that you're providing and where you could fit yourself in. So, is there a rehab unit where perhaps, you may admit some patients who do have the cancer diagnosis or cancer needs. Is it purely outpatient? Will that outpatient be in a satellite? Will that outpatient be in that rehab center? Is there an option for that outpatient to be multidisciplinary? And there's various benefits and pitfalls to each. I personally actually am very fortunate that I purely practice in multidisciplinary clinics. And so I'm fully embedded within our spine service at MSK. So I practice alongside our neurosurgeons, our radiation oncologists, our interventional radiologists and our anesthesia pain doctors, where spine is our organ and we're all focused on that. And the benefit for that is really we're giving the patients more comprehensive care and they're able to see everybody at the same time. And there's that added benefit for me in that my no-show rate isn't very high because patients tend not to cancel on their surgeon and they tend not to cancel on the radiation oncologist. And so when they're there and they're seeing me, it's that benefit. The other benefit is if you're thinking about our patients who have any mobility needs or high-level needs, if we're all in one place, they don't have to travel. So what is your overall global environment? How many different places where they need to be seen? And how can we make that easier for them? And thinking about it, if you're in an academic medical center that might have a cancer center that's offsite, perhaps embedding yourself in there and how can you actually do that? So really understanding that structure and how you could use that to your benefit and also really understanding what the needs of the medical center are and how do you drive that patient choice to come and being able to build that program. In addition to that, really understanding what services do you have in terms of lymphedema, in terms of the physical therapists and the occupational therapists and neuropsychologists, case managers and social workers that you may need. Do you have relationships with DME vendors? Do you have relationships with orthotists? How can you use all of that to really enhance the care that you're providing? And what is the ability to have those patients, excuse me, have those other providers alongside you when you're taking care of these patients? And so as you're thinking about this, also thinking about the job roles. And if you kind of notice the way I highlighted these job roles, they kind of sort of align with promotions, right? So where is it that you ultimately see yourself? You wanna build this program, but what's next? So do you wanna remain on a clinical track where everything you wanna do is very patient-focused? Are you that clinical educator where you now wanna play a role with the medical students, with the residents, with the fellows? Are you thinking about being core faculty for a residency program? Are you thinking about being an assistant program director or program director? Are you thinking about building that fellowship? And how does that now align with what you're doing from your day-to-day, but also on your tenure track? Similarly with research. And when we think about research, there's purely research tracks, and then there's that clinical researcher. And how are you going to spend your time? How much of your time will be spent clinically? How much time will be spent from a research standpoint and thinking about what that means in terms of the funding that you're going to need? And then administrative roles. Are you going to build a program? Are you going to be the medical director? Are you thinking about administrative roles that you can have in terms of director of a service line, a service chief, a division chief? Do you ultimately wanna move on to that, even thinking about chair? And how is that going to impact your time? How much time clinically versus how much time your attention will be somewhere else? And in these administrative roles, I think about it not only at your institution, but outside, because sometimes you wanna be on different committees and you wanna advance your career in those ways. And sometimes you may also find that it's those outside things that you're doing that really drive you and really help in terms of your own personal mission and your own personal growth for what you're wanting to do. And again, how all of this is going to relate to the patient care versus the non-patient activities. And I think in the day and age that we're in, we're always having to think about how am I spending my time? How am I justifying my time? And how do I wanna find a balance? And I think balance is gonna look a little bit different for all of us. And so I run our fellowship program. So I always wanna make sure that I have time for that. There are administrative tasks that I do for our service, but also for outside organizations as well. I am a committee chair on rehab standards in the American Spinal Injury Association. So how am I balancing that in terms of my overall time? And also where do I wanna spend my time? So I've really taken the approach that, I spend time in clinic when the neurosurgeons are there because they're my main referral sources. So I align my clinics with them and I've managed to get my patient volume enough that I could do it on the days that they're in, but then also have that administrative time. But I'm still seeing enough and kind of able to find the time for all the things that I'm wanting to accomplish. And so just a sense of what career advancement and promotion looks like. And I feel like everyone should ask what the promotion tracks look like and what do promotions mean in the medical center you are. And also for the medical school. So we're unique in that I have a promotions track for Memorial Sloan Kettering and I have a promotions track for Cornell Medical College and they actually look very different and the requirements are very different and the timing is very different. And you really have to understand how to navigate that because you wanna advocate for yourself. And yes, there are some that are very happy at the assistant level and they're willing to stay there. But I really want you to think, and I really argue that if you're wanting to build programs and you're wanting to advance your field and whether it's purely just in cancer rehab, or for me, I really wanna bring cancer rehab to spinal cord and as I'm being promoted and I can have a title above assistant and I can move to that associate or even that professor that really helps that cause and it really helps the messaging that I'm giving because it looks like I've spent that time and I've done my due diligence and you can be that expert in your field. And so it's important to know how you're spending your time and what track you wanna fall on. And it's not something that you have to decide right away but usually within your first two years, something to figure out. So the most common tracks when we're thinking about it are the clinical educator and I think that's where a lot of us fall. So we're finding that balance between patient care and also the amount of time that we're spending educating the trainees who are with us, but also giving presentations at a local level, at a regional level, at a national and international level. There's then the clinician scientist. So finding that balance between clinical care and research. And here it's important to really understand how much research and how many papers you're actually writing to make sure you're meeting that need. You can then actually look on in terms of an overall research, tracked as well. I don't think many of us do fall on it, but there are some who do. And ultimately the clinical track. And to be honest, when you're thinking about career advancement, being purely clinical is actually really hard to then advance because you need to show that you're making a difference within your area. You need to show that you're presenting and that your name is getting out there. And then even beyond this idea of promotion, it's actually where do you ultimately see yourself in a leadership position? And so where we can actually do that is in terms of the clinical care that we're providing. So we can go from this idea that we are that clinician to, or the director of a specific program, to we might be a division chief or a service chief, to the idea of being a chair, to even thinking above that. Do we want a more medical director type role? Are we thinking about, could we be the chief medical officer of the institution that we're on? But not only just in our institution, we think about clinically, what does this mean in terms of our society? So taking on leadership roles on different committees, thinking about how you can then advance in terms of board leadership, or even can you lead one of our organizations? And so thinking of it from that clinical area, how can you get involved with your medical schools? Are you interested in that undergraduate piece of things? So more from the medical student perspective where you could be a preceptor, a course director, can you be on the clinical curriculum committee? Can you be on the admissions committee? Do you think about being a dean or starting as an associate dean of rehab medicine and how can you influence in terms of the medical school from that perspective? Similarly, thinking about the ACGME, thinking about the ABPM&R, other educational organizations and where can you fit with that if you're not thinking within your own institution. Similarly with graduate medical education, so thinking about it more from the resident and fellow perspective. So being that clerkship director, being core faculty, being an APD, becoming a program director, and doing more again within like ACGME, ABPM&R and getting more involved in that. And then for that research role, perhaps that is really what's driving you and you're really interested in questions that you can answer and how your clinical care can drive these research questions. And how do you move on from a research project to being potentially a co-PI, to being a principal investigator, perhaps leading a research fellowship? How can we play more role thinking about your IRB? Can you play a role there? And really trying to bring the rehab perspective too and really using all these things to advance the field. And I know this slide here really shows how it works in family medicine, but I think we can actually look at it from the overall perspective as well. And so with that, I say, thank you. I know it was a lot of information, but hopefully I was able to demystify academic medical centers a little bit for you because I think we oftentimes think we know them, but at the same time, the more time we spend in it, we understand the layers of navigation that we may have to go through for the programs that we're wanting to build. Thank you so much, Dr. Rupert. Loved hearing about the three pillars in academic medicine and how they support each other and drive each other. Carolyn, are you still on? Are we gonna get cut off hard at 8.15 after or? No, you can go ahead and continue your discussion if you need to. Okay. Yeah, take your time. Great. I'm sorry. So anyway, we are technically at the end of our time in about a minute, but if you are able and willing to hang around both our panelists and attendants, first, thank you everyone for participating today. These have been great presentations, and I'm sure that we have some great questions potentially from our audience. I wanna introduce my co-chair, Diana Molinares. She is assistant professor of the Department of PM&R at the University of Miami Miller School of Medicine and director of Oncology Rehabilitation Medicine for SCCC, program director for PM&R Residency Program, as well as for the Cancer Rehabilitation Medicine Fellowship. And she is going to be running and driving our Q&A session. So Diana, please go ahead. Thank you, Leslie. Thank you to all our panelists, and thank you for staying a little bit longer. I just wanna first start by opening to our attendees to see if there is any specific questions about the different presentations that we have. Yes, and you can also put them in the chat, and I'm happy to read it if you're not in an environment that can be read. So Armand is asking a question. He is a second year PM&R resident, and interested in a style that may involve a mix of inpatient and outpatient setting. And then some of the presenters talked about the settings and the trend and what the overall trend looks like in terms of job markets, the complexity and the barriers. What are you things are the complexity and the barriers of the different markets in the next five to 10 years? In your different settings. Okay, I can go first. Dr. Stubblefield, were you gonna say something? Yeah, I mean, that's pretty straightforward, right? So it's much easier to bill efficiently in inpatient. That said, we're constantly looking to have barriers of reimbursement as Medicare in particular is trying to cut those reimbursements. We're competing with nursing homes and some acute centers. Outpatient, again, it's volume, right? If you're running 12 patients a day or 20 patients a day in outpatient, you're running a fairly busy clinic in our world. Inpatient, you know, you can see 30 patients a day and you're billing higher for them. There are a lot of places that need good inpatient rehabilitation attending. So we have several in select medical who would be delighted to have people who really wanna specialize that and make that a big part of the practice. That said, it's also possible to do an inpatient practice and see a few outpatients. But again, you know, just you may do that because you enjoy it. I personally really like seeing outpatients, but it's not gonna be nearly as efficient. But, you know, if you are seeing, say, spinal cord injury patients as an inpatient, somebody needs to follow them as an outpatient. It's often great if it's the person who first treated them. I think that Dr. Lau had other comments about this question. I was just going to say in my experience in the community. It really is what you want to make it if the opportunities are there and networking. And so if you have a vision. It's really just a matter of finding someone who is willing to support you and and help you create that vision. I was going to mention that. Oh, go ahead. Um, first off, I kind of like a little bit of everything, as in I kind of like inpatient a little bit more, but obviously that's not the setting I'm in. So I would encourage being flexible, depending on what's important like location practice settings, what's important for you in terms of job market. I think that there is so much need in cancer rehab. There's so much. There's so so much so there may not be a job where you want it, which was my case. But it's possible that someone will see the need and create a job for you. And so you can be a proactive go getter and make the job you want. So, of course, there's a lot of complexities with that. Also, and at least speaking for Southern California. There was maybe 10 years where Cedars-Sinai had one cancer rehab doctor than 2020 got a second. And then I was the third in Southern California. And this year there's going to be three positions open so it's really hard to say but I think the job market is growing and the desire for cancer rehab is growing pretty quickly in the last few years. I think it's about thinking what is it that you're you're bringing. And so I came everything with the lens of spinal cord into cancer and, you know, filling a need that there weren't many who were able to provide. Is it that you're also interested in the idea of doing injections or even if you really like that inpatient. So what is it that aligns with your personal mission. And then thinking about it from that perspective and then how do you bring that and and I think it's when you can show the care that you're wanting to provide and you're bringing that service you're making those patients want to come. And I think it's as all of us are doing that in different models. I think that's what's also allowing cancer you have to grow because we're showing that it doesn't need to be one size fits all it could be we can meet the needs of where you are and the practices that you have and help you expand those. Thank you, everybody. I think one of the goals of the main goals of our talk today was to show the variety of jobs opportunities and as well as different settings where you can practice cancer rehab and how being a cancer rehab doctor in one place looks completely different from a different place. I think we have another questions here. It's for Dr. Chamba whoever can answer. Could you talk a bit more about some of the pushback you have come across from pain interventionists in treating cancer patients and if how you have been able to effectively respond to and overcome this. I actually can cannot think of a case where I got pushback so I have a great relationship with the pain interventionists at the other campus there. They adopted me into their division since I'm the only one. Interventional pain is also under supportive medicine, and we are weird alike in that we do in clinic procedures so there are some times where we overlap in procedures, or, you know, we just communicate and build a relationship I've gone and shadowed and they appreciate PM&R and the different perspectives, the physical exam that we do. I'll ask them if they can see a patient that's closer to them and doesn't want to travel to me, and vice versa. In that sense, PM&R has been kind of Switzerland between neurology and interventional pain, because interventional neurology will do. I'm sorry, neurology will do some migraine Botox but not all of the patients in my area want to travel to the neurologist location. So I might chip in here and there so I've been good with, with these parties but that's where I stress the communication and building personal relationship is extremely important to have that collaboration. I just had a comment about procedures. I think it was really interesting about some of the discrepancies with that. So, Jessica, you said the procedure half day is less productive. And then I think Michael, you said the opposite. And, you know, this was meaningful to me because a couple years ago I had to decrease my EMGs from three half days a week to one and I was really worried that would negatively impact my practice, which has kind of been a wash. So, fortunately, has not been negative, but I've heard our interventional pain people say that their half day of procedures is actually generating less revenue than their E&M day as well. And I think that's especially the case for the image guided, the ultrasound, the fluoro guided, not for, you know, landmark guided where we tend to do really on the fly in clinic and then also being a teaching hospital, more time is built in for the teaching. So, I'm thinking it probably really depends on, you know, those sorts of contextual things of if it's teaching or if it's image guided or, you know, those kind of factors. So, I don't know if there's comments about that, but great presentations overall. I don't even really know where to start. Couldn't say any more things, but I won't. Hey, Mary, great to see you, first of all, and I think you're right. It's all about efficiency, right? So, if you're only doing three or four procedures, that's not going to be efficient. And if the ultrasound guided, it takes so long, the cost of materials is so expensive, you know, I'm old school, so I don't even know how to turn the thing on and I'm able to do all my injections without it. So, you know, if I wanted to do, you know, 50 cervical Botox injections in a day and just line patients up, I could. I just go from room to room with everything set up and I have a two hour lunch and still be fine. So, it really just depends. But if you're sitting there scrambling, set it up and getting everything sterile to do your ultrasound, that's going to take a very long time. So that was kind of the point I was making is it's about efficiency. And so many of us on this call are in an academic setting where the financial pressures are very different. If you can only eat what you kill financially, then it's a very different situation with how you're going to be efficient. And I moved from that academic space to the private practice E sort of academic private space and with very much for profit therapy services where you have to be efficient or you have to close the center. And Jess, I was really nodding my head on the trigger points. There's just so many patients that find that valuable. Right. How many do you do in a day if you wanted to? Right. If that was all you were doing, go to the next patient. I think the lowest RVU generating, but it's just the value is so high. And I agree with you, Michael. It's all about efficiency. And, you know, there's a lot of factors outside of myself, no matter how hard I try. So, you know, it's hard to make small increments when the field is ripe for a small increment. But it's so complicated. But, you know, I do think that sometimes, even if those RVU for time is not so great, but in terms of building a clinical practice, it's great when oncologists feel comfortable enough to message me and ask, like, hey, do you do this? Do you do that? And I think that's part of the building the clinical, the E&M side also. So it's efficiency really is kind of the key from a business perspective. I guess on that similar note. Sorry, Jessica, you were going to say something. Oh, I just neglected to mention nerve conduction study and EMG as a procedure because we haven't been doing it. But that's that is a thing. So speaking about the financial administrative aspect of these procedures or in general in the practice, what are some of the biggest financial and administrative pitfalls that you guys encounter in your different type of settings? And what are some of the major operational and financial challenges that you have to overcome in your practice to make sure that you have a profitable, successful practice that either supports your salary in academics or that generates revenue in a private setting? OK, I'll go. I think when you're building a new program, the patient numbers, the patient population, just getting your numbers as quickly as possible, getting your clinics full, that has been a challenge. It would be a challenge wherever you build a program. And I think I thought that it would come more quickly and it hasn't. And so I've been working on navigating that. To piggyback off what you said, Kelsey, the data is important and it's hard when I can't get the data in real time or as timely as I would like. And so instead of sitting back and waiting for it to come, I think it's important to be proactive and try to calculate out your RVUs or try to project what kind of clinic template it would meet your RVU goal, if that's how your practice is set up. And then resources might come later, but not to wait on other people to give you that data. That's a point I don't know if we've made in terms of building your practice, because I didn't really talk about that. We always talk about improving the function and quality of life of our patients. I'm a big believer in improving the function and quality of life of my colleagues. And that's always been kind of my superpower is I take care of the stuff they don't want to and I let them know that I'm taking care of the stuff that they don't want to. And once you kind of take that on, they're like, oh, yeah, please take my patients. Right. So I think it's just kind of a thing to keep in mind about who your actual client is. If it's certainly the patients, you have to do it, but it's also your colleagues and they're the ones who are sending the patients to you. A lot of what I do is actually helping our surgeons and our radiation oncologists sort through where symptoms are coming from, where someone is symptomatic. And so looking at it from that perspective, too. So not just on the backside, but how can I help up front? How can I help with that diagnosis? And then following the patient through that continuum. And and really, I think it's the minute you have one person in your corner, they then help champion you and then you have another person in your corner. And a lot of times you can build that referral network from those champions or those stakeholders, however you want to look at it. That's how you're going to build your service. And a lot of it just starts with bringing those patients in, increasing that volume, showing your worth and then putting that together in terms of, you know, I can really just do this and I can sustain myself doing this. And then how do you grow that even bigger? And you always have to think in terms of, you know, how much does it cost to have me? And I think sometimes when we think about the procedure piece is how much is going into the added expense of doing that procedure versus how much are we getting back? But how much does it cost to have me and how can I justify that cost? And what am I doing in terms of volume or complexity or even thinking about how much time you're spending for patients and how you're building that to help that piece? So using those stakeholders and and really getting their buy in to increase that volume and also really thinking about the care that you're able to provide and how are you justifying that to the billers so that they're reimbursing you for it? And those two pieces kind of go in hand in hand. Michael, I thought I heard you say you weren't a big utilizer of the time based billing. Did I understand that correctly? And I mean, I do time based billing a lot. Yeah, no, I'm wondering about others or why. Yeah, I'm doing level three, four, five in the outpatient service. Everybody's a four or five. Every new visit's a five just based on time. But you don't always. So when I do a lot of opioid management as well with these patients and opioids because of the monitoring automatically kicks you up to a level five follow up. So once you go to that level five, what I meant there's actually codes, I believe, in 10 minute increments. I wrote the chapter in the textbook on this that you could justify like adding on. I've never used those codes above sort of a level five initial or follow up. Thanks, Mary, for bringing that up. I actually exclusively bill by time. And I use all those prolonged services code. And the coders and billers have been happy with me. So I'm getting all my time compensated for the day of service. I think I use a mix of both depending on what it is that I'm doing, how much patient education. So if I have a new spinal cord and I'm going through bowel, I'm going through bladder, I'm going through a lot. There may not be a lot of complexities to what I'm talking about, but I'm spending a lot of time. But then if I'm doing more of a diagnostic eval and ordering imaging, ordering different tests, thinking about the medicines where your complexity is there, I think kind of looking at both and ultimately what is most appropriate so you don't have to do one or the other. Also thinking about the setting. Are you doing this in an inpatient setting versus an outpatient setting? And how complex is the visit versus how much time? So you always kind of have a little bit of a mix of both. I want to speak back to Diana's question. It's really got me reflecting about administrative pitfalls. So I found myself in these two, three years getting frustrated because maybe someone doesn't know what PMNR stands for. You're still calling it pain medicine and rehab, which is kind of true, kind of, but I don't have that subspecialty certification. But what I've learned is that every time I'm frustrated, I need to stop, not show it, and remind myself that these people mean well. Hopefully the people around you do, but I know our leadership, they mean well. They're not doing this out of maliciousness. And there's always something I don't know, some bigger picture, some bigger context, something that executives have been talking about. And so that's really helped me throughout the years to get frustrated less and less and to build these relationships with the executives and just stay humble, stay collaborative, stay smiling and be like, hey, I know you want to help, but how do we do this together rather than seeing some people as the other side? Yeah, I mean, I'll just echo that. It's a great point. Now that I'm, you know, again, working in a private sector for a company with 50,000 employees, you know, it is very interesting what our operators have to deal with, and it is at a much higher level. So it's never perfect from the people who are sort of delivering the care, and the operators know that it's not perfect, but sometimes it's the only path forward. So I think, great point, Jessica. Well, I think we can keep talking about many other things and have more questions, but I want to be respectful of everybody's time, and we are over, I think, 20 minutes by now. I, Dr. Begay, are you around to close the session? Thank you from my end, everybody that took the time to be here, and thanks for joining the presenter for taking the time, as well as the audience for being here and taking time of your Thursday night, Tuesday night, Dr. Begay. Thank you, Diana. Yeah, great questions, and I think it's a great sign that we went 20 minutes over. Thank you, everyone, for sticking around and for our panelists for sticking around. Diana and I are both very thankful, and our Cancer Member community is as well. So I hope everyone has a great night, and we can continue these talks at the National Conference for those of you that are able to attend in the fall. Have a great night, everyone.

Cancer Rehabilitation

Leslie Begay

Business Models

Financial Sustainability

Operational Challenges

Billing Efficiency

Referral Networks

Interventional Procedures

Patient Quality of Life

Academic Medicine

Collaboration

Strategic Planning

Career Advancement