So welcome, everyone. I am Leslie Begay. I am the current chair of the Cancer Rehabilitation Medicine member community and very happy today to host our cancer community session. We have four speakers with us today and the topic is going to be talking about cancer rehab fellowships. So introductions, one of our panelists is Catherine Power. She is the program director for the Cancer Rehab Fellowship at MedStar National Rehab Hospital slash Georgetown. Cat has been involved in the fellowship training program for the past five years and has been program director for the last two and a half years. She herself did complete a fellowship in cancer rehabilitation at MedStar Georgetown. And I asked all of our panelists to tell us something that they love about their role and job. And Catherine said that she loves training fellows in residence and helping cancer survivors any way that she can. All right, then our next presenter is Christian Custodio. He is a physician at Memorial Sloan Kettering Cancer Center and associate program director for the Cancer Rehabilitation Fellowship. He has been involved in the fellowship training program for 14 plus years and he himself did complete a fellowship but not in cancer rehab. So maybe when he speaks, he can tell us what that was in. And he loves mentoring as well as building relationships with other people in the specialty. Our next panelist is Rajesh Yadav. Did I say it correctly? That's correct. All right. And he is program director of the Cancer Rehabilitation Fellowship at UT MD Anderson Cancer Center. He has been involved since the creation of the fellowship there in 2007. He did not complete a fellowship himself as there was no fellowship at that time. And he created the first year long fellowship. Something that he loves about his role and job is being able to assist very medically complex patients and families, both in terms of improved quality of life and being able to qualify for a necessary treatments as well as assisting new trainees, whether they're residents or cancer rehab fellows or fellows from other programs to understand and develop skills in the field. Diana, are you, she texted me that she was logging on but I'll just maybe start with the first question and then we can introduce her as she goes. Okay. So for this panel, we have a number of questions. I'll address it to one of our panelists. And then after that panelist speaks for a couple of minutes then the other panelists are free to add if there's anything else that they would like to speak about. So let's see, since I introduced you first, Catherine, we'll ask you the first question. So in preparing for fellowship, if a PMNR resident wants to work with patients with cancer, what additional skills or knowledge does a cancer rehab fellow obtain that would make it desirable to complete a fellowship versus not? So great question. Glad that we have the opportunity to talk about what makes a fellowship important. And there's lots of opportunities out there, which is wonderful because as was alluded to earlier, this has not always been the case. There are several reasons why it would be advantageous for some. So unfortunately, as it stands right now, a lot of the current rehab residencies don't actually have a lot of cancer rehab exposure in that they don't have a particular attending that does that all the time. They may have someone that sees some cancer patients, but maybe that's only part-time and the residents maybe don't get a chance to fully engage with that kind of patient population. Fellowship not only allows you to form relationships with providers that see cancer patients regularly, but learn specific skills that may be more applicable to that population. For example, at our fellowship, we spend time learning particular procedures that I would not have been exposed to had I not done a fellowship because they're a little bit more specific to the cancer population. For example, toxin to the neck was not something I was exposed to as a resident, but because of the head and neck cancer population and instance of radiation fibrosis and limitations, doing a fellowship allowed me the opportunity to get a little bit more skilled and more comfortable learning procedures that way. There's also lots of benefits because you get mentored in working with people already in the field, guidance to start a program. I think that goes into maybe some other questions that will be answered later. So I will pass the baton on to someone else who has a different perspective why it's awesome to be one of us. Thank you. I mean, echoing Catherine's comments, we deal with a very special patient population which comes with a whole bunch of unique needs and impairments that are very specific to their surgeries, their chemotherapy, their radiation, their stem cell transplant, their immunotherapy, you name it. It helps to immerse yourself in the oncology training population. So working side by side with the radiation oncologist, the medical oncologist, surgical oncologist, and learning how to communicate with them and speaking their language and educating patients on what we have as cancer rehab physiatrists that can benefit them. And helping them manage, helping the oncologist manage these patients along their entire treatment continuum. It's a very special and fulfilled role that we play. That we play. Okay, I'm gonna go to the next question. So Rajesh, if you want to answer this one, if a resident is interested in exploring a cancer rehab fellowship, what opportunities should they seek out as a resident? And is there a value or what value is there to trying to do an away elective at an institution in cancer rehab or another area of rehab? And how else might a resident be able to stand out as an applicant? Yeah, I think that's a tough one because Vish Raj had published a study some time ago and to a large extent, it still may be true where majority of the human residents may not have much exposure to cancer rehab. So it becomes a little tougher to seek additional knowledge. But if one is indeed interested, then you can start with attending conferences, whether it's national conferences, otherwise participating in lectures, journal clubs at institutional level, research opportunities if they're there, one may participate in that. And taking electives. Those are some of the things that come up at least at a residency level. In my experience, when I was in residency, I didn't intentionally go into PM&R thinking I was going to go into cancer, but I thought I was going to go into sports. And I said, hey, I'm going to go do an away elective. It was a great elective, but there was something kind of missing for me. And so I kind of talked to some of the people in my residency program about what I was looking for, wanted to keep my medical knowledge to really help improve people and work on their function, but I just didn't necessarily find that patient population that just appealed to me innately. And so in speaking with some of my program's attendings, they said, oh, you know, it sounds like maybe you'd be interested in cancer rehab. And so they gave me the name of somebody. He spent an hour on the phone with me just talking about what that might look like, a cancer rehab fellowship, and some advantages of doing it and how he found it to be really meaningful for him and what he does. And literally just that conversation made me hopeful that, hey, maybe this sounds like something I'm interested in. So if you even think that you have a small interest in it, even just seeking out someone that does this and having a conversation, just like most rehab professionals, we're very approachable and we're very enthusiastic about what we do. So it's very easy if somebody reaches out to me, I'm gonna do my best to try to speak to them and kind of give them an honest feeling about what it means to be a fellow in cancer rehab and what they might experience and see if it's right for them. So literally just ask us. Yeah, seek out these kinds of opportunities, these community sessions. Some residency programs, unfortunately, don't let their residents do away electives. So for some people, it can be challenging. In those instances, just reach out to Dr. Power, Dr. Yada, myself, and or any of the attendings on this talk. We're more than happy to exchange emails, to talk and start the mentoring process. Yeah, speaking of which, I've done quite a bit of marketing, Christian. Yeah, if I'm not mistaken, Dr. Obasi, I may have convinced him, given him our sales pitch, and he has joined us in the meeting. And I just recently talked to someone in someone up Northeast also. Just talking about cancer rehab in general, we talked for an hour or so. Once again, the cancer rehab professionals are, we're all, we're an enthusiastic bunch. And if anybody is interested, they should reach out to one of us. I wanted to touch base on, what's the value of an away elective? It's like doing an audition rotation. If you're interested in any subspecialty in any fellowship, you do get a chance, if you're interested in a specific program, to get a lay of the land, see how things actually function at a grassroots level at that institution. You get a chance to maybe talk to the current fellows and see how they, what their experience has been like. So it can come with minuses too. If you don't do well on your rotation, it gives us as program directors an idea of maybe you're not the right fit for this program. So it's like any other rotation. I would like to also add in the fact that our, I think that our former graduates, fellowship graduates have been instrumental in talking to a variety of trainees and steering them towards fellowship because of their own positive experiences. And yeah, I think there's definitely a value in away elective. At our institution, for example, just the sheer size, and I'm sure Sloan Kettering is no different. The sheer size of the place, it just kind of, there's a different feel to it. You get to see cancer patients day in and day out, and you get to decide if that's what you want to do. Great, thank you all. Okay, so our next questions are going to be revolved around the fellowship itself a little more. And we'll, let's see, direct this to Christian, Dr. Custodio. So for a fellowship program, do all fellowship programs focus on rehabilitation of cancer patients, both in the inpatient and outpatient settings? Are multidisciplinary clinics available at some or all fellowship programs? And why might considering or thinking about these aspects be important for residents? The quick answer is no. Our fellowship program doesn't offer an inpatient rotation. We do not have an associated inpatient unit. But we have opportunities at our sister institution, Weill Cornell, across the street, where a fellow can do an elective in inpatient rehab if they wish to. That's kind of the beauty of all of our different programs is each one's unique. Each one brings a different system, a different flavor to the table. So there is a little bit from the fellowship applicant standpoint, they need to do a little bit of research, they need to do a little bit of shopping around and see what type of program do you think would best serve your particular clinical research practice interests. If you're more interested in doing inpatient cancer rehabilitation, I will flat out tell you, our program's not for you. If you're not interested in living in a big city for a year, our program's not best for you, right? You need to find the program that fits your personality, your clinical and research and intellectual interests. So same thing holds true for multidisciplinary clinics. I'm sure we all participate in one form or another in tumor boards, so we do get to all interact, at least on a didactic or rounds level with our oncology colleagues. But there are some unique multidisciplinary clinics that each of us have instituted at our places where we get to work side by side with radiation oncologists or anesthesia pain colleagues or bone marrow transplant teams because cancer is this whole spectrum of diseases and every type of disease, every type of cancer has different impairments, different needs, different strategies that we as physiatrists can implement. And it helps to actually educate our oncology, the oncology fellows, our oncology attending colleagues on what it is we do and how it is we do it. And I think the patients initially are a little overwhelmed when you have this multiple, several medical teams kind of converging on them, but when they see the communication that's going on and the coordination of care that's going on, and it gives us honestly a chance to educate our patients, our oncology colleagues on PMNR in general, not just cancer radiation. So if I may, I would like to interject a few comments. You know, PMNR is generally a downstream specialty. So we're sort of at the mercy of other referring physicians and many, as such as our own institution with the support and so forth as to what we do. So I think historically speaking at MD Anderson in the early nineties, there was a push to try to do something as far as inpatient rehab for complex patients. And so, and of course, over a period of time, things have evolved. So once again, it's important to consider that this referral base, this idea really leads to the type of cancer practice, cancer rehab practice we have, and thus, in return, what the cancer rehab trainees experience. Cancer rehab, we're defined it as a fairly, we cast a fairly wide net in terms of what we're trying to do for the patients. And so we have, we deliver ideally cancer rehab care in three venues, outpatient, consults, and inpatient. And I think all of us are a little bit different because of those things that I just mentioned. And these differences really should be celebrated because we all are not, you know, if the field is so big, we can all kind of choose what we are able to do within that construct. Anyway, just wanted to throw that in there. No, thank you both. And I wanted to just interrupt for one second to introduce our fourth panelist, Diana Molinares. She is present there with us now. She is Program Director and Cancer Rehabilitation Medicine Director at the University of Miami. She has been involved in the Cancer Rehab Fellowship Training Program for four years, and she herself did complete a Cancer Rehab Fellowship. And something that she loves about her job and role is how much that she learns and gains the perspective from patients and her trainees. So Diana, welcome. And I am going to bring you right in and gear the next question to you, if you're ready. Okay, so we're talking about during fellowship. Our Cancer Rehab Fellows, now we just heard how all the fellowships have different pros and different unique characteristics about them. Do all the Cancer Rehab Fellows get training in how to develop or start a new cancer rehab program following graduation? We know that cancer rehab is building and growing, and there's a lot of places that don't have fellowships or cancer rehab programs at all. And I know that I've seen from my time with the community, a lot of graduates starting programs at institutions. So if you could speak to that. Yeah, so good evening, everybody. I apologize for being late to the session. I had an emergency on the floor. So patient care first. But I am very honored to be here today. I think that, yes, because of the growth of the special team, there is a lot of opportunities for leadership and for building programs. I think that's one of the advantages of doing a fellowship versus not doing a fellowship in cancer rehab. Depending on the institution where you're trained, there are possibilities that you have some expertise with the clinical management of the patient or the cancer patient. However, that expertise in terms of navigating the system, understanding what the system needs in terms of the cancer rehabilitation patients, it's much appreciated when you are involved in a cancer fellowship program. Because then you can learn the intricacies of how communicate with the oncologist or what are the needs in your institution or the institution where you're going to, as well as like what are the different areas of cancer rehab that you can develop that you may not be exposed to that during the residency period. But yes, a lot of our graduates go ahead and start new programs. I had the opportunity to start one here at University of Miami. And my fellowship was at MD Anderson. And definitely my experience there for the year that I had was very useful at the moment of starting a new program at University of Miami. Like I said, a lot of the graduates have done that, but now that the field has grown, it continues to grow, but there are established programs that are also growing among themselves, like between themselves. So there is a need for if you are somebody that you, yes, you want to practice cancer rehab, you want to be part of something, but it may not be that you want to start a new program. There is also that option to join a program that is already established or that it's growing. And definitely when we have cancer rehab, the institution gets so excited that they want to grow so much. And it kind of like tends to grow fast. So I think that we have seen that in a few programs where the amount of faculty that they have grown and those are coming from the graduates from the fellowship programs. I completely agree with what Diana was saying. Not only do you kind of learn nice approaches to interact with your eventual referral sources, you know, like how to talk to oncologists, what do you want to approach a surgeon with and kind of show your value. But you also, in terms of a fellowship training, you can get involved in committees and understand how you can bring something to an accreditation board and kind of show off and say, Hey, this is something that would be part of the guidelines and that you're sewing, hey, we have rehab, we have services. Furthermore, when you're in fellowship, you learn about certain things that you may not fully know if you're going to go and start a program on your own, like you most definitely will need wonderfully trained physical therapists, occupational therapists and speech therapists that know how to work with cancer patients. How many do you need? Do you need them in different locations? How are they going to be trained, all those kind of things that are so important. But if you don't actually do a fellowship, you may not know what the ask is when you go in to start a program. So you learn a lot about those types of things. So if you do end up starting a program, which is still, you know, a heavy lift. So nice job, Diana, for showing us how it's done. But, you know, you'll feel much more comfortable. Furthermore, you have an established mentor in your training, like all the people that have graduated from our program can turn to me or my colleague, Dr. Wazowski and say, Hey, I know I graduated three years ago, but this question or that question, and that's really helpful. I think just from a selfish subspecialty standpoint, we want more programs out there. So it behooves us as fellowship training program directors to, you know, to make sure that that skill set is in place when you graduate. Right? Yeah, I tell our fellows on the first day, think of this as a year long job interview. And we would love to hire you. But I know for the good of the field, you need to go elsewhere and establish roots and start other programs at other institutions. And that's how the field grows. Thank you all. Alright, so my next question is going to focus on what happens after graduating the fellowship. So Catherine, back to you, I think in the rotation, what types of job opportunities are there currently for cancer rehab fellow graduates? And is there any difference? Is this any different than for an individual that does not complete a cancer rehab fellowship? And does it matter if you're pursuing a job, for example, at an academic institution versus a community hospital? So I think I kind of jumped in there a little bit on my last answer. However, I do think that there's a little bit more to it. So firstly, there are plenty of jobs out there. There are jobs for people specifically with cancer rehab training. And now recruiters institutions are really looking for, ideally fellowship trained cancer rehab providers, because that's something that says, hey, they've done this for a year, they know what they're doing, they come with this like establishment, so to speak. And honestly, some of these institutions don't know all of what we do in a fellowship. So whether you train and you do a lot of inpatient, or you do a lot of outpatient, literally just having that on your resume gives them a peace of mind that says, hey, look, they're coming with cancer rehab training, they're going to know what to do, they're going to be coming here to help expand our program to start this program to deliver for these cancer patients that need rehab, and we want someone with this skill set. Just like even though there's opportunities for these kind of cancer rehab programs, there's also opportunities for people that want to go to places and say, hey, look, I have this additional training. I know you're not currently looking for a cancer rehab program, but I am someone that wants to start one and wants to see cancer patients, you have this cancer center, you're missing all this referral possibility, I'm more than happy to do part time regular rehab or more neuro rehab, if I love that, and then slowly build my cancer referral source so that I can do more cancer rehab. I also love EMGs, maybe I'll do two days of EMGs, maybe I'll do three days of cancer rehab, there's so many different options out there for people. And honestly, it just comes to what moves you and it can be more than just cancer rehab. And that's why you really have to figure out what appeals to you and then kind of look because it's the first time in your life where it's not like, oh, I just really want a job. I really want a job. Now. Hey, look, I am a cancer rehab fellow, I am graduating. Look at what I bring to the table, I am actually wonderful, and they want me, let me sell myself because they're gonna want me. It's, it's a little weird, I have to say, I remember that first time I was like, Oh, this feels like the tables turned, and I'm not comfortable with it. But you should be you should be proud that you just did this. And you're bringing something to a lot of different institutions. So that's a very oversimplified way. I think other people can add to it. So I just wanted to say since 2007, we had our first graduate who went to Los Angeles, he came with this idea of doing something with cancer rehab, and a position was, I think, created for him. And many of our earlier graduates had positions created for them. Meaning they they said, Hey, I want to be in this kind of area, geographic location, or I like this place. And they would talk to someone either in cancer center or at a specific institution, this is what I can bring to the table. And they will say, Yes, sure, we'll go ahead and create a position for you. And I think that as as cancer rehab has taken hold, increasing hold. Now there are cancer rehab specific opportunities. Some of the graduates also had a scenario where they would do some cancer rehab patients and some regular rehab patients, and they would wait for the practice to evolve and grow. And, and there's things that things did, they would go increasingly into cancer rehab only. So anyway, just wanted to throw that in there. I think that one of the things that sometimes it's not very obvious, or that that doesn't jump right away is the ability of a cancer rehab physician, I don't know if you talk about this, I'm sorry, of doing procedures and having a practice that is more procedural. Because some some people have this idea of cancer rehab of thinking that is very clinical, which could be for somebody like me that likes inpatient and more that clinical aspect more than procedures is great. But also for those that are more procedural inclined, it doesn't mean that cancer rehab is not procedural based in that they can, there are no opportunities to develop a practice for a few days a week or an entire practice based on procedures that are specific for cancer patient. In fact, I will venture to say that there are like a lot of more opportunities to be resourceful and creative on the on the type of procedures that you do with the patients and also opportunities to develop them more and provide more research in that area of what can be done on these on these population. So I think that's an aspect that that sometimes gets underestimated, but it is it is very important and very necessary in the treatment of these patients. Yeah, I would agree the you know, the procedure skill set that we all bring to the table as physiatrists, knowing how to apply that to our cancer patient population is a skill set and a learning objective in and of itself. Getting back to Leslie's introduction of me, I didn't do a cancer rehab fellowship, because like Dr. Yadov, they didn't exist back when I graduated from residency. So I actually did an EMG fellowship, a clinical neurophysiology fellowship. And that was kind of my backdoor entrance into cancer rehab. Because when it came time to looking for jobs, knowing and Memorial Sloan Kettering was actually looking specifically for an EMG-er with a strong interest in academic physiatry. So knowing what kind of unique, you know, pathophysiology that cancer patients brought to the table, you know, and doing those EMGs day in and day out. That kind of what started my role, or my path in all of this. So I think it's yeah, it's knowing what you want to do. Finding the tools and the skill set necessary during your training in residency and fellowship, and then selling that to interested people who want to start cancer rehab programs, who understand the value and the need for it. I was actually a little jealous of all my fellows this year, with all of the different job offers and opportunities and interviews they went across the country. That didn't happen with me when I graduated from fellowship. So yeah, I think it's all about knowing what you want to do. Yeah. All right. So, Dr. Custodio, since you finished, but we're going to start our next question with you. So how, and it's kind of a very vague question, so you can answer it however you'd like. But how would you say that you set your fellows up for that to us? Like, the first issue is how do you define success, right? It's how you define personal success? You know, do you want a job taking care of cancer patients day in and day out? We can certainly set you up for that. Do you want to start a new program at a new academic institution? As we just talked about, you know, part of our training and our training objectives in fellowship is to teach you how to, you know, establish lines of care, whether it's an inpatient line of care, whether it's a academic or research line of care, or pathway, you know, we want to give you the school, the tools necessary to do that. You know, do you want to start, you know, down the road a fellowship program at your institution? We have, you know, we show you examples of how we at our institution, at our program, set up these different lines of consult care, education, of research, of program development, and give you the experience and, you know, the mentorship necessary to do that, wherever it is you want to go. You know, that's the beauty of fellowship. It's the, to me, it was the best year of my training career. It's when you got to immerse yourself, you know, in a subspecialty of rehab, that truly stoked your passion. And you learn how to use that those skills, and that knowledge base necessary to do whatever it is you want to do. And you rely on the mentors at your given program, and in this community, to help guide you, you know, and to kind of ease that transition stress, if you will, as much as we can. Anybody else like to speak to how they set their fellows up for success? Yeah, I think that the echoing the sentiments of Dr. Grissudio sort of depends on what it is success means, whether it's clinical care, establishing program, clinical program at another institution, establishing cancer as a rehab training program of some type, and research, right. So at the very core is how do you deal with how do you deal with this patient set of patients who are medically complex, have dynamic issues going on, including symptom burden, how comfortable you are in dealing with various other specialties, at a physician position or institutional level, being able to communicate rehab needs of this group of patients, and getting PM&R involved in various clinical pathways. How do you promote the field? You know, and of course, doing research, because that's, you know, everybody wants to look at data and what do you bring to it. So I think that, once again, looking at what constitutes a success for different individuals, we're all trying to meet, meet those needs through the training program. I think the one advantage of not being ACGME accredited at this stage, is that we have the flexibility, like in our program, if you come in, and you're like, I am so passionate about X, Y, and Z. And maybe right now, we have some experience in that I can pivot and give them more experience in that if possible. You know, like, oh, you found working with this oncology practice or this provider to be really helpful. Okay, let's expand that opportunity. We have wonderful providers and our other subs, or other specialties in cancer, surgery, all that kind of stuff. And if you feel like that experience is more valuable, especially depending on what the patient population you're hoping to, you know, focus on, if you want to do more bone marrow, if you want to do more solid tumors, whatever the scenario, the nice thing is, like, at least in our fellowship and many of them, whether the fellow is there or not, my practice doesn't change. So it's really about, you know, educating them, giving them the educational opportunities that are most valuable to them. So whether they're there in clinic to do notes with me, or that doesn't matter, so much as we get them exposed to patients in all types of patients in oncology care, and we can educate them in the best way possible. So if they want to do more procedures, if they want to do more EMGs, we'll make it happen. And that's the nice thing. And that can make people feel more comfortable, and thus set them up for success. I 100% echo those comments. It's the same, the same mentality that we, we have, and I think most programs have. I was gonna add to that, that I like around halfway through the fellowship, you have a pretty good idea where you're going to work or what kind of setting you would like to be in. So I feel like, you know, the second part of the fellowship is so important to kind of like tailor your training to like your new job that is waiting for you. So it's kind of like, you know, you're trying to get as much knowledge for that specific thing that you are planning to do moving forward. So I think that's a great opportunity and comes with the flexibility that Dr. Powers was mentioning. Thank you all. I have another question kind of building off of some of your responses. So it's a new question. So I won't assign it whoever wants to speak to it can volunteer. But we talked about the unique aspects of different cancer rehab fellowships. And I think I've heard some residents ask me, you know, well, I'm interested in treating patients with cancer, kind of speaking to the procedure, or an aspect of the procedures. Why should I do a cancer rehab fellowship as opposed to an interventional pain fellowship? And I know a few of you talked about obviously things that maybe you don't learn in a pain fellowship, like doing spasticity management or doing EMGs. But maybe if any of you could add a little more insight into that. It's okay. Yeah. For me, for you, when I sit down with residents who are interested or torn between pain pathway or cancer rehab pathway, they need to do some introspective. What about each subspecialty really attracts you to it? You know, what's the patient population you want to take care of? You know, for me, it's taking care strictly of the, you know, the functional impairments of cancer patients, not just the pain management aspect of it. That said, we do have some colleagues who have gone the pain fellowship route, and have returned to Sloan Kettering, and are dealing strictly with cancer pain. So that's another, you know, potential pathway that people can do. You know, they're doing the fluoroscopic procedures, and they're doing some, you know, cryoablation treatments that I certainly am not familiar with or trained in. But they're not doing spasticity management, they're not doing EMGs. You know, so they're not doing, you know, diagnostic musculoskeletal ultrasounds. So it's, you need to, you know, weigh the pluses and minuses of each of those. And what it is, you know, what do you see yourself doing day in and day out, you know, over the next several years? Yeah. And is that enough to get you out of bed, excited, and going to work? I would say, go ahead, go ahead, Diana. I was gonna say that, you know, there are some pain fellowships that give you the background of cancer, but not all of the pain fellowships. For example, if you do a pain fellowship at Sloan Kettering, or if you do a pain fellowship at MD Anderson, you're going to be seeing enough cancer patients that is going to make you comfortable with that population. But I can tell you that if you do a pain fellowship at an institution where cancer patients is not the common type of patients that you see, you may not feel comfortable enough to treat some of the cancer patients because there are some, no limitations, but considerations and precautions that are needed, depending on the treatment, the cancer, the treatment, or the plan of care that this patient is going to get. So, I mean, it's totally fine to go that route. And what we want is for the cancer patients to have the best, you know, treatments possible. But if the idea is to do pain fellowship for cancer patients, I will recommend something that it's the next institution where you're going to have enough exposure. I would say that for for fluoroscopic guided procedures, that is something that you are interested in, that is a good route to go. But for other procedures, especially ultrasound guided, or asbestos EMG, but lately, we're doing a lot of ultrasound guided procedure, to be honest, in this population, for that a cancer fellowship, and not a pain fellowship will be a good idea or a good route to go to. So, yeah, I'd like to piggyback off on what Anna said. But I guess one has to ask what it is that one wants to do. I mean, cancer rehab is, there's a lot more to cancer rehab than just pain management. So if you're interested in pain itself, and if you're working at an institution, a big institution, it's easy to see how pain management could take up all your time. But you know, for example, at MD Anderson, there's actually a cancer pain fellowship, and they're former PM&R, you know, PM&R folks from PM&R background who have done that fellowship, and all they do is cancer pain, they don't necessarily do anything as far as cancer rehab. There is a, you know, if you look at a Venn diagram, I guess you could, you will, you will see some commonalities in terms of what Dan was saying, you could do ultrasound guided procedures, and I don't think the cancer pain folks here do anything with Botox for pain. But once again, this idea of pain, it's not just about doing a procedure, you know, if you expand a little bit more, there's more going on, and rehab has to be a part of that. So I'm not sure if I'm giving a great answer, but I think it just boils down to what the individual wants to do. If you're interested in pain medications, management, fluoroscopy based injections, then pain fellowship is the way to go. The way I look at it and the way I usually start my intro to cancer lectures or insert intro to cancer rehab is that cancer rehab is rehab. It's just for cancer patients. Just like you do an EMG fellowship and you end up the cancer rehab fellowship director or you do a spinal cord fellowship and you work with patients with metastatic cancer to the spine, also one of your colleagues does that quite a bit. There's definitely a lot of different ways to treat cancer patients and I just think that pain fellowships are wonderful for people that want to focus on pain relief, but when I think about cancer rehab as a whole, pain is just one section of it. I mean it's about function. It's about quality of life. It's about fatigue. It's about energy levels. There's so much to it and it involves a lot of knowledge about the oncological treatments and the journey that they go through. So I think it all comes down to, as everybody said, is it your goal to treat pain or is it your goal to really treat cancer patients and should be hopefully a fairly straightforward question if you fall into one or the other and both of them are completely acceptable. I'm biased towards one obviously. Thank you all. I think you really did touch on what makes the cancer rehab fellowship special and unique as opposed to other experiences. So we're getting closer to the end of our time and I do want to leave some time at the end for questions if our members have any, but so just ask each of the panelists if there's any general pearls of wisdom or guidance that you would wish to share with perhaps some residents that are either watching this live now or will be watching this video later as they're considering pursuing a cancer rehab fellowship. We're letting the wise, the wiser people speak first, so Dr. Yadav and Dr. Custodio, you can... I'm not quite clear on what I'm going to comment on. Can you just rephrase it for me just a little bit? Are we trying to... Sure, sure. So if we have residents who are viewing this video either now or in the future, any general wisdom or guidance that you tell your residents or residents that rotate with you if they're trying to decide on cancer rehab fellowship or how do I pick the right one for me? Anything else that you haven't talked about yet that you might want to share with our audience? Yeah, I think getting exposure to cancer rehab in general, whether it's through electives, whether it's through just very basic lectures or just talking to one of the cancer rehab physicians, that'll be a great intro and then that way you can decide if that's something you want to do. Yeah, I use the analogy as like, think back when you were in medical school and applying to PMNR, what made PMNR so interesting to you that you wanted to pursue that as a field? You need to take that to the next level of what is it about cancer rehabilitation that is so interesting that you want to pursue it and make your career. And then when you decide that, then you can start researching the different programs and the different opportunities. And in that regard, we'll reach out to any of us and we're happy to help navigate or help you navigate that system. I would say that cancer rehab comes in different flavors, shapes or forms, so explore. You may have an experience or an idea of what cancer rehab looks based on the exposure that you have at your institution or your experience that you have had with cancer patients, whether or not it's in a cancer rehab specific setting. So if you have that curiosity and you want to learn more about it, don't just go based on one experience, but try to see the different avenues and aspects. And I think we have spoken extensively about that, that you can do with cancer rehab. And then the last thing is that it's awesome, that it's great to work with the cancer patient population. Yeah, I would say the most striking thing about the fellowship for me is that in residency, I very much felt like a learner. When I was in fellowship, I felt almost more like a colleague and that I was really getting trained to feel as comfortable as possible. And straight from the gate, it was very much a comfortable relationship with your mentor, your program director. And that was immediately noticeable. And I think that's just the nature of residency versus the nature of a fellowship. But in the setting of treating cancer patients who are dealing with a lot, and sometimes emotional and sometimes going through things, it felt very nice to have that relationship right from the start. So if you are thinking, hey, this might be for me, part of it is not just where you go and what the experience is like. It also comes down to, hey, Dr. Custodio is a really nice guy. I feel like I could be very comfortable talking to him about my future goals. Maybe that is a good fit for me. Kind of figuring out some of the, just the comfort level you have with the program directors, not just the program itself, because those are the people that you're going to be talking to for several hours, for several days, for an entire year. And it goes by fast. But that's an important relationship to have. So you want to feel very comfortable with it. Thank you all for sharing those pearls of wisdom with our audience. I want to open up the time now, if anybody who is present for this panel, if you have any questions, please text them in the meeting chat. And we actually do have our first question that's up. So I will read it out loud. And then whomever on the panel would like to answer it first, feel free to tackle it. So the first question is from Dr. Jessica Engel. How do you think we will continue to cultivate the Cancer Rehab Fellowship in the future? And what do you think the future holds? Probably give you 15, 30 seconds to think about that. I think we've got PGY1s and PGY2s here in the audience that are already interested in seeking out more information in cancer rehabilitation is a good thing, right? So, yeah, we need to recruit residents and market, sell the field of cancer rehab, sell our fellowship programs. And we touched on this earlier. I kind of want my fellows to go elsewhere and establish roots and hopefully, knock on wood, establish training programs wherever they end up and continue to expand that field. And the educational aspect of our subspecialty more. I think it's exposure and like showing them how cold it is. I think people have a preconceived notion of what it could be or based on one or two experiences sometimes. I just think that if we have the opportunity to showcase more how diverse and how much you can make it your own, the cancer rehab aspect, then I think people will be more in tune with doing a Cancer Rehab Fellowship. And I think the future is great. I think that, you know, we're going to unfortunately need more cancer rehab doctors. And if it's a matter of like, is the market too saturated or not? Well, you know, I can tell you that the cancer rehab demand, it's just growing. It's not a lack of opportunities out there. So I think those opportunities are going to be attractive for a lot of trainees and also an opportunity to make it their own. And so I was going to add that, you know, I've been at MD Anderson since 1999. And one of my colleagues, Dr. Shin says that when we first started, there were a handful of us in the country that did cancer rehab. So that's 25 years ago. Since then, cancer rehab as a field has grown phenomenally. There was no training opportunity, even for residents, a lot of residents. And fellowship, first fellowship started in 2007. And so, and you can see the number of fellowship programs we have. And so there is increasing presence of cancer rehab at a national level, not just clinically, but also in research domain. American, I'm trying to say there's accreditation for accreditation body through committee on accreditation of cancer. No, anyway, I'm sorry if I don't have the name quite right. But this is, this is through, that's it. Yeah. Commission on cancer accreditation. Yeah, I think in 2000 or 2019, maybe I want to say. They also added this verbiage to the institution cancer centers that if you're going to claim that you have cancer rehab, you need X, Y, Z. You just can't say we have a part-time physical therapist coming here once a week or twice a week and call it cancer rehab. So that added this added that they added this thing of having a cancer rehab physician in there. So I just see the field growing. I see there's increasing opportunities at variety of levels. So hopefully that answers that question to some extent. Yeah. And I, as we said earlier, like selfishly for the field itself, we want more and more cancer rehab physicians because we want more oncologists, more surgeons, more cancer providers to understand what we do and what we offer. It's wonderful that many of them now can view us and understand what we do, but there's still a large number that don't and don't know what we can offer. So the more that we can bring up and train, the more that that becomes abnormal. And that will in turn, give patients more opportunities because I can't tell you how many times people said, Oh, you know, I had cancer 20 years ago. I had none of this. Now I have cancer. Thank you so much. This is such a smoother experience. You know, like I got right into PT or I did this right away. And it's the difference is night and day. And so it would be nice to have that for more patients. Thank you all for answering that one. I have a question from, I think a physician, Dr. Abisi, who may be interested in a cancer rehab fellowship is asking what is the ideal time and duration for residents interested in cancer rehab to complete away rotations? If they are able to, I'll answer that one. Dr. Abisi, first of all, is our is a graduate of our fellowship program. And he's, he's highly capable of highly capable cancer rehab physician. And he's working in Chicago right now. And he went through this whole ordeal of establishing a cancer rehab program. And he's, I think he's having great luck. He's trying to recruit someone else. So I just wanted to first throw that out there. And from at MD Anderson Cancer Center, I typically encourage folks to do away elective in their third year, PGY three. So that way they've, they've gotten some basics of TMR down and then they can, they can add this. And that also allows for a PGY four where they can say, okay, this is kind of what I want to do. And we can start sending our applications in because a lot of the interviews tend to be in July, August, September. And then, you know, last year we started this mass process where the results were declared by mid December. So that's why I'm suggesting junior year PGY three. Yeah, I would echo that, you know, end of PGY three, early PGY four is probably your best time to do an elective on a way elective. If you play risky, the later you do the elective, I guess the more fresh you can be in that program's mind when it comes to interviews. But yeah, the match is in December of the preceding academic year. And so most programs are going to be interviewing September, October. So try to get your rotations in before then. Anybody else have any questions for our panelists? Oh, I got one more. Okay. So one of our members is asking that, well, they're stating they are taking a different type of fellowship route. They will be starting a hospice and palliative fellowship in July. How might a separate cancer rehab fellowship enhance, add to, or complement that fellowship training? I can't answer that question because in the fellowship that I did at Indy Anderson, we actually worked very closely. I don't know that that's still the case, but at least when I did it, we were very closely with the palliative care fellows and also the palliative care attendings and some of the lectures. So I think there is a, it's a wonderful opportunity and you're going to learn a lot of different skills that are applicable to cancer rehab. The difference is the approach. I was just talking to one of my colleagues that is a palliative care physician, and she was talking about how amazing like cancer rehab is and so forth. And there are some areas where we overlap in terms of like improving quality of life, decreasing some of the side effects of like all the treatments, for example, chemotherapy induced peripheral neuropathy. But our focus is a little bit different and our expertise is different in terms of more focus on function and, yeah, function and mobility with other different tools and different approach. So with the palliative care, you're going to be going very heavy into symptom-based. I kind of like address that symptom-based versus with the cancer rehab, you're going to have some tools that are going to be more on the preventative and also on the enhancing function component of the cancer rehab. I would like to add to Dr. Molinares' comment. As she said, we're within the Department of Palliative Care, Rehab, and Integrative Medicine. So rehab, PM&R is actually a section within this department. Having said that, our training program is what I call heavily seasoned with supportive care symptom management. But things to keep in mind is at the end of the day, what is it that you want to do? Because if you're dealing with cancer population, you can have your hands full just with palliative care. Please understand that the type of people, people's background, I should say, in palliative care necessarily is not from PM&R. So you could have a family practice doctor, you could have internal medicine doctor, you could have a variety of disciplines applying to these fellowships. So palliative care physicians necessarily may not really know much about PM&R. Yeah, so I think, and also the type of patients we get, we have prehab, so that means patients who have just been diagnosed with cancer and still waiting for, you know, there's some delay in terms of starting initial treatment such as surgery. So you could be doing rehab with those patients. On the other hand, when you're looking at palliative care, still the referrals may be later down the line versus sooner. Leslie, you're muted. Thank you. We just have a couple minutes left. So I saw one other question came out, and are there any resources you would recommend getting familiar with prior to a cancer rehab away rotation? I'm going to make a plug for the Cancer Rehab Tumor Board here, because they meet, I believe, every month, every other month. And this is a, sorry, Kat, I couldn't hear what you said. I was saying maybe quarterly. I don't actually- Oh, quarterly. I think it's every other month quarterly. But anyway, those are great opportunities to discuss cases and kind of get a flavor of cancer rehab. So if you do it like throughout the month, then you can have different type of cases and see the variety. So I think that's a great opportunity to see it and to hear discussions among different cancer rehabilitation physicians. And also an opportunity for you to meet or get other people in the field that you may feel comfortable reaching out to. So having a conversation. When I was at PGY-2, I was like, I don't know if I'm going to do this or not. And I called one of the cancer rehab attendants, and I spent an hour on the phone with him just talking about what cancer rehab was. There was no these opportunities, but even a phone call one-to-one answering all the questions can also prepare you for the rotation. But I think that the tumor board will be a great opportunity from the knowledge standpoint. I'm not sure if we're going to get cut off at 8.15, but I just wanted to take the opportunity to thank all of our panelists again. Dr. Yadav from UT MD Anderson Cancer Center. Dr. Custodio from Memorial Sloan Kettering Cancer Center. Dr. Molinares from University of Miami. And Dr. Power from MedStar National Rehab Hospital slash Georgetown. Thank you, everybody. I hope whoever has been present at our talk, please look at the resources on the AAPMNR website. And as our panelists mentioned, it is an amazing community to become a part of. So please join our member community. And also, please feel free to reach out to individuals in the field because they are more than willing to share their knowledge and expertise and help you along in your process. Thanks, everybody, for participating. Thank you, everyone.

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