Cancer and Inpatient Medical Rehabilitation

Welcome to Medical Rehab Matters. Today we're talking about inpatient medical rehabilitation and cancer. The American Cancer Society estimates that there will be about 1.9 million new cancer cases in the U.S. this year. And many people benefit from inpatient medical rehab at different points during and after their cancer treatment. Today we'll be talking with some of the leaders in cancer rehabilitation in the U.S. I'm Patricia Sullivan, Director of Communications for the American Medical Rehabilitation Providers Association and co-host this episode. With me today is co-host Dr. Robert Krueg. Later in this episode, you'll hear from Dr. Michael Stubblefield, Director of Cancer Rehab at Kessler. The first we talk with Dr. Vish Raj, a cancer rehab specialist at Carolina's Rehab and Sarah Mullin, an occupational therapist and manager of cancer rehabilitation at the Levine Cancer Institute. So thank you both for joining us today. We're really excited that you're here. Dr. Vish Raj, you are the Medical Director at Carolina Rehabilitation and also with us is Sarah Mullins, occupational therapist and rehab manager at Levine Cancer Institute. Thank you so much for being here with us today. We really appreciate it. I'm just going to jump in with our questions and that is why is a hospital's rehab team so important for cancer patients? So cancer is sort of an interesting diagnosis. It's probably one of the most prevalent diagnoses in the country if not the world. But yet in the rehab world, it's a population that's under certain, some of that has to do with tradition and culture from the 60s, 70s, 80s as we had 75% roles, now 60% roles. Some of that had to do with cancer as a diagnosis in terms of survivorship and how people lived after initial treatments and now improvements from those treatments. And when you put it all together, you now have a population of people who weren't traditionally considered rehab patients, but actually are living longer and longer, have more disease-free survival, have less toxic treatments that allow them to have better quality of life. But yet they still have functional deficits from all the interventions that are necessary to treat the cancer, whether it be surgery, radiation therapy, chemotherapy, etc. So when you look at rehab and you look at the opportunity to help a new population that we've previously not been able to provide accommodations to, I think there's a very exciting, philosophy, very exciting approach to this group of individuals. Yeah, I mean, I think for thinking about impassioned rehabilitation specifically because I think, you know, outpatient rehab for the cancer population is much more sort of widely known and much more prevalent. I think from the impassioned perspective, you know, the cancer diagnoses are different, but the impairments that these folks have from their treatments are very similar to every other rehabilitation diagnosis that, you know, we all learn to treat in school. And so although the cancer diagnosis is different and maybe, well, definitely the trajectory of their disease is different than, say, a patient that had a stroke or a spinal cord injury. The thing is that they need from a rehab perspective in order to go from acute care to hopefully go home or move on to the next level of care. The things that we're treating are very similar from a therapy perspective, certainly, from a OTPT and speech perspective. So to be able to have these folks in an inpatient rehabilitation setting where they have rehab nursing, social work, dieticians, PT, OT, speech, the rehab physicians, all there in that one setting, it's really the best thing for their buck, right? They get all the services right there, have typically a pretty short length of stay and then they can hopefully get home to get on with their life. You know, Raj, I remember sitting at a couple of the Academy of Physical Medicine Rehabilitation Annual meetings in the last few years, pre-pandemic, where they throw up at the cancer or special interest group meetings, you know, the fact that, you know, at least two thirds, if not more patients with cancer diagnosed, he's really would benefit from rehabilitation. And yet it's, again, you know, to your both of your points, it's really not something that I think often in the acute care hospital setting and often in the outpatient setting that the oncologists are really thinking about. I mean, I think now over the last couple of years it's become a lot more front and center because of the work of providers like both of you. But if you could just sort of expand on that a little bit more so that those that are listening could, you know, advocate for themselves, you know, what should they do to ensure that at least they're assessed to see whether they're appropriate for rehabilitation services? Yeah, no, that's a great question, Bob. And, you know, it's so interesting you bring that up because even today, even with as much work as we've done to move this field forward, the question still comes up where people will ask, well, you know, what's the relevance of rehab to the cancer patient? What's the role of rehab in acute care? What's the value at? And when you think about it, I think there's two approaches. So, you know, traditionally all of us who are clinicians, you know, come at it from the patient care perspective and we say, well, gosh, if you consult, you know, you're going to have a patient who's a pain in our physician or you consult PT or you consult OT on a cancer patient, especially in acute care, you have the opportunity to try to improve performance status for a patient so that either they become stronger in anticipation of future treatments or you address issues that might be related to their quality of life. But there's another angle that I think is even more important and probably has more leverage than just the patient care aspect. The other avenue that you can explore is the concept of utilization management and acute care utilization metrics. So, you know, when you look at IRF and you look at the criteria for admission IRF, you know, many of us go by the 60% role, we go by the medical necessity arguments and often we're boxed into this idea that all the diagnosis we have to admit are stroke, sprain, injury, spinal cord, and apetese. I'm sorry, Josh. I don't mean to interrupt, but just for our audience, they may not be familiar with IRF and your return to inpatient acute rehabilitation. Right. Yeah, sorry. Inpatient rehabilitation facility or hospital rehab. What I like to call a rehab, although I think several other settings try to claim the name, but that's what I call a rehab. And so, when you're looking at admission to rehab and you're looking at your 60% role, people forget that you have this 40% you can play with. That actually allow other patients into the hospital. It goes along with medical complexity, medical type patients, but cancer is one of those primary diagnoses. When you look at the 60% role, cancer also fits in in the 60% role. So you look at brain tumors, you look at spinal cord tumors, you look at amputations from cancer. These are all very common diagnoses that are also compliant. Right. So you have two angles where you can actually improve access for patients to go to inpatient rehab because people aren't always thinking that way. You're a two-care guy's think, "Oh no, rehab is for strokes. Rehaps are for the other stuff." The other leverage point you have is when you look at discharge dispositions from acute care, you would think like people would have thought about this, but given the predominance of cancer in the acute care hospitals, we really don't have great pathways to take care of the cancer patient from acute care unless they go home. And back in the day when oncology patients were allowed to hang out in the hospital for 30, 60, 90, 120 days, that might have been fine. So when you're trying to manage a length of stay in acute care of one week, two week, three week, and you have oncology interventions that are needed including chemotherapy radiation, and you're trying to look at the different options you have for post-acute care. So, you know, inpatient rehab, maybe skilled nursing facilities, maybe LTACs. They're not like on the surface well designed to accommodate this, but actually if you look at those three inpatient settings and you look at who has the most flexibility to accommodate the cancer patient, it actually is inpatient rehab. And the reason why is because more often than not, the cancer patients meet the medical necessity criteria that we need for Medicare standards. They could meet the 40% or the 60% part of the year 60% role. And if you put it together well and you have professional clinicians who are very skilled and treating cancer patients, you can actually provide for very efficient and effective stays where you can provide rehab care and oncology treatments all at the same time. Sarah, as you guys announced earlier, she's manager at the Lean Cancer Tutor where we do a lot of our outpatient cancer rehab prior to that. Sarah was actually the leader of our inpatient cancer rehabilitation program from an operational side and from a therapy side. And so, Sarah, you probably have some more insights about the utility of inpatient rehab and how we made it work in our setting so that became a really effective way to deliver care. Yeah. I mean, I think for. You know, folks that are first starting out, you know, thinking about starting a cancer rehabilitation program for inpatients or wondering, you know, a lot of places have these patients that are coming to their rehab, but they don't have a program around it. So they're trying to sort of tie that up and package it in with a nice little bow to say that they have a cancer program. And so likely they're already doing the work. They're already seeing some of the patients. I started at CR around the same time. And when he came in, he said, you know, we're going to start this cancer program. And everybody was like, what? Why? You know, to be honest, why are initial team really thought, what are we going to do, you know, to help these folks? And are they too sick to do the things that we want them to do? And they participate in three hours of their via day. And so it really took a while for everybody to get comfortable for the team to get comfortable with what the goal was and what we were doing. So Sarah, I think, you know, you bring up some excellent points that just because there's an inpatient rehab facility or hospital doesn't necessarily automatically mean that, you know, they have an expertise in cancer rehab. And so for the patients in the audience, please, you know, ask the appropriate questions. You know, you can tell a lot by going on to a website and seeing if a program is certified. Is there a physician, you know, who is sort of designated as the champion for that program? Are there therapists dedicated to the program and so forth? But maybe you could expound on that a little more. What was your journey at Carolina's to get from just sort of having an interest in it to really creating the program that it is today? Yeah, I think having that well-defined team was the sort of biggest hurdle and the most important step, you know, finding the people who were interested in this population and who just sort of got it. And there's no better way to explain that. But I find with therapists at least once you start doing cancer rehab, you either love it and you are passionate about it or you are like, this is not for me. For one reason or another, from the therapist side and from the nursing side as well, we started meeting together as a group with the physicians. We had our strong physician leaders. We did journal article reviews. We developed competencies that we all had to take. We met and did case reviews of past patients, what went well, what didn't go well, and just had those monthly meetings as a team so that we could start to identify as a team. And so we could learn, I mean, having the strong physician leadership, it was invaluable because we didn't know what we were doing, right? And it was just very little out there. We tried to find continuing education classes and there just wasn't a lot. And so we sat in our weekly sort of care team patient review meetings and said, what's the plan? What's their prognosis? What's our goal? And it took the team a few years of doing that to really get comfortable with what we were doing and what our goals were. And even now, as a various established team, we have that conversation very, very early. What is the reason that this person is here? What is our goal? Are they currently getting radiation? So they need to stay here while we get them stronger because if we thin them out to a skilled nursing facility quickly, they're not going to get their treatment anymore. Are we trying to get them in, train their family and get them home so that they can be home? We still have those conversations early on about what is the goal of care for this patient and family? Sarah makes a good point because what she's really expanding upon is the goals of care, right? And I think it's an important thing to understand that when you look at inpatient rehab and you look at how you can deliver care for an individual of cancer, you can deliver care for people who categorize all throughout the spectrum of care in the oncological trajectory. So what I mean by that is inpatient cancer rehab can be applied to somebody who's just been diagnosed with cancer, who's starting their treatment. They can be applied to people who are in the middle of their treatments or maybe past the initial phases of treatment who have longer-standing problems from the treatment. And it can also be applied to folks who are at the end of life who have other needs in terms of trying to make it home, have better quality of life, family training. So it's really important to understand that when you deliver cancer, rehab care, you can do it through the spectrum of care. If somebody at the end of life, you can't do anything for them. Of course you can. There's so much you can do. And if somebody's in beginning a treatment, there's a ton of stuff you can do. And if somebody's in the middle of just ton of stuff you can do, so it just requires a certain amount of flexibility and creativity. Do you know how to apply the rehab principles of cancer patients? I'm so glad you mentioned all that because that was actually the question I had on my mind is at what point in the cancer treatment do people, you know, with a stroke, it's after the initial emergency, you go into rehab with an amputation. It's after the initial peeling, you go in for rehab. And with cancer, it can be such a long journey. It can be such a long treatment land. And there's always the threat of no longer being in remission and getting sick again that I'm sure is hanging over the heads of patients and their families through the whole process. Does a good cancer rehabilitation facility or hospital, are they prepared to help with those aspects of cancer patients and their families? I mean, so when you look at cancer rehab programs across the country right now, there's one organizing body that provides like an accreditation or certification for cancer rehab, at least in the US, not internationally. And in that organization's, you know, criteria, one of the critical pieces to ensure that you're being in need of the family and also providing the resources necessary to get a patient what they need regardless of where they are in their trajectory. And I think that's an important point because, you know, when you look at an inpatient cancer rehab, do you know right? Traditionally, when you look at amputees or strokes, you know, there's a well-defined time course from when somebody would qualify for rehab. There's a well-defined time course of how long you expect them to be in the rehab hospital and then they'll well-defined goals in terms of what you're hoping to accomplish as somebody can transition to the next level of care. And I think in cancer, we have the same discussions, but the trick of it is you have to know where the patient is at and you have to know where the family is at. And then you have to adjust your plans accordingly so that the patient and the family can get the maximum benefit for the intervention you're trying to provide. And we didn't very lucky. I mean, Sarah gives us way too much credit. You know, we all started, yeah, none of us knew what we were doing. We knew we wanted to help people, but we didn't know how and we didn't know why and, you know, we had everybody coming up against us saying, "Ah, it's going to work because these folks are really sick and I think it's going to cost too much money and it's too resource intensive and all this stuff and you know, but in the end, if you really think it through and you know what you can do for rehab and you know how you can apply that to different patient populations, what you figure out real quick is that you can actually not only apply the rehab principles to folks throughout the spectrum. You can meet the needs of the patient and the family based on where they're at. And you can actually make sure you have a sustainable program both clinically and physically so that this can continue onward and upward." And so, yeah, no question. A good cancer rehab program can address the needs of the patient at the given time with their given functional and medical deficits. And not every program is created the same, not every unit is the same, right? So if you're starting with a very small and patient rehab unit and you want to take cancer patients in there, you know, if it's a 10 or 15-bed unit, you may not want to go after the most medically complex patients' treat because you may not be ready for that. So maybe what you're treating are folks who are a little less complicated, somebody who's at a brain tumor that's been taken out. So it's very much like a brain injury or a stroke or somebody who's got a spinal tumor so it's sort of similar spinal cord injuries where the amputee is like we talked about. But then as your program evolves and your program expands and your team gets more and more confident in their skills and they understand how to apply the principles, right? You might be able to expand into the patients who are receiving chemotherapy. You might be able to expand into patients who are getting radiation. You might be able to expand into patients who have what we call liquid tumor diagnosis, things like lymphoma, leukemia, multiple myeloma. And even though the medical care gets more complex, the principles are still the same. And then once you really get comfortable with all that, boy, you can have a tremendous impact. And you know, for our program now, on the inpatient side, I think we would argue that we are not exclusive to any cancer diagnosis at this point and we're not exclusive to any treatment. So if patients have active oncological treatment that's necessary, we will take them, we will accommodate it. If they have very complicated medical diagnoses and complications that are extremely complex from the cancer diagnosis, we will take them and we will address them. So you mentioned occupational therapy. You've been an occupational therapist and I think there's a lot of confusion about what that means because people think occupation, I'm a farmer. Yes. That's not what you're talking about at all. So occupational therapy really looks at what folks need to do in order to participate in their daily activities. sort of make up their life. So this can look different based on, you know, whether you're inpatient or outpatient, but from the cancer perspective, you know, these folks have physical and cognitive impairments, whether that's caused by the cancer itself or the treatment they received. And a lot of those, whether it's trouble with memory or processing or problem solving, whether it's trouble with balance or strength or fatigue or range of motion deficits, all of those things can impact the way you do your daily activities. And that can be super simple activities of daily living, like bathing, dressing, getting it out of the shower, some more complex things like driving, working, cooking, cleaning, things like that. And so that's sort of the way I, you know, have always thought about OT is I'm really just looking at what does this person do every day? And then what are the little functional things that they need to be able to do to be able to cook? There's a lot that goes into that. I need to be able to reach every head. I need to be able to use my fine motor skills to open things. I need to be able to follow directions and process the recipe. I need to be able to move throughout my kitchen, whether that's in a wheelchair or walking or using an assistive device. So all those little things that we do every day without even thinking about them, now that there's a disruption in some of those, you know, places of function, it can be really, really hard for folks to get back to doing those daily things. So that's what OT does. And I think, you know, OT for somebody with cancer can look super similar to somebody that, you know, has had a stroke or has had a spinal cord injury. Can I go if you comment on specialty certifications, either for individual providers or for programs? Yeah. I mean, from a step from a therapy perspective, the only therapy discipline that has a specific specialty certification is physical therapy right now. So through the APTA, you can get a certification as an oncology rehab specialist. And so that's something that PT's are starting to, you know, apply for. But really what our therapists have is specialty certifications, treating the impairments. So we have therapists who are certified lymphedema therapists. We have therapists that are, you know, trained in dry needling and pelvic PT and treatment of layer injectemies and dysphagia therapists. And so we really look, are looking at the impairments that we're treating and getting our specialty certifications there from a facility perspective, you know, some things that we did. I can't even remember how many years ago now, but the commission for accreditation of rehab facilities car, you know, has all sorts of certifications for inpatient and outpatient rehab. And our facility had a lot of those. And then the first year that they had a cancer rehab specialty certification, we applied for that. And so we got our inpatient certification that year and got our outpatient certification when we started our outpatient rehab program a few years ago. And so that is something, especially from an administrator's perspective. That just is something that I, the way that I know that we're doing what we're supposed to do. It's all of these different standards saying what excellent cancer rehab should look like. And so I go through those and check them all off and make sure that's what we're doing. And that's what we really built our program around. I think you've been modest if carf is the gold standard. And if memory serves me correctly, I believe your program was the first first or second in the nation right to get that certification. We were the first inpatient facility in the world. And we were the first outpatient rehab facility within a cancer center in the nation. I think for any program that's looking to build a program in cancer, it's good to review what those standards are for accreditation because it gives you a much better perspective about what you're really aiming for, whether you go through with it or not, I guess is your choice, but it definitely gives you direction. And then just to follow up on your question about Sarah talked about therapy and she talked about organizational accreditation. And then from a physician point of view, there are cancer rehabilitation fellowships in physical medicine rehabilitation around the country. We host one of the fellowships. There's about nine I think through the nation. And it's so interesting because each fellowship is so different that you get a different level of training at each institution based on what their strengths are. So I think it's important if you're a program that's looking to grow, if you're a patient looking for a physician, one thing you may have to be mindful of is not all cancer rehabilitation physicians are created equal. So there might be some with more expertise in procedures and pain management. There might be some with more expertise on inpatient rehab. There might be some who are more musculoskeletal based or maybe some who are more based on lymphedema. And so I think that's just important that if you're looking for an expert and you know what it is you're trying to get out of that expert, maybe it's worth reaching out to that provider and trying to find out what their skill sets are to make sure they can meet up with your needs are. I want to thank you both for all your time and really appreciate your time and your help today. Yeah, thank you so much for having us. Yeah, it's been great. It's always great to talk about cancer rehab. It's always great to talk about it with folks who are really interested. And I hope maybe for those of you who are listening, maybe this stimulates you or excite you to either participate or develop something in cancer rehabilitation wherever you are because I think there's a huge opportunity across the country and for cancer patients to make substantial improvements in the quality care. This episode is brought to you by Murrus Therapeutics, part of the Murrus Group, a privately held family-owned company. Murrus Therapeutics is committed to improving the lives of patients who suffer from movement disorders, spasticity and neurological conditions. Focusing on advancing neuro-modulator technology, Murrus Therapeutics offers Xiamin, a uniquely purified therapy that's FDA approved for six therapeutic indications in the United States. Please note that Xiamin has a boxed warning and could result in potentially serious life-threatening side effects. Visit ciamin.com for important safety information and full prescribing information, including a boxed warning. You will also find information on how to connect with a local sales representative, reimbursement specialist, or medical science liaison. In our next segment, we talk with Dr. Thank you for joining us. Thank you. I appreciate you asking me. So, Michael, cancer rehabilitation, as you know, you can't go to a rehabilitation conference nowadays without this being a topic that is front and center. Certainly, there are conferences just dedicated to this topic alone. I think there's been a big recognition over the past really decade, but particularly even the last five years as to the number of patients that are either going through cancer treatment or a survivorship has certainly increased, who really would benefit from rehabilitation interventions, whether those are as an inpatient or as an outpatient. And I would love it. You could just share with the audience your perspective from 30,000 feet and then we could sort of dive in from there. Yeah, thanks so much, Bob. There's what, 16 million cancer survivors in the United States, a number that's growing effectively, exponentially. As our population gets older, it's very much a disease at the age of, although, you know, younger people certainly do get it. At least half, depending on how you're looking at it and who you're looking at, of these patients will have some sort of functional impairment as a result of the cancer and very importantly, the treatment of cancer. So this is a huge population of cancer survivors who have issues that rehabilitation is in a unique position to try to evaluate, treat, to improve these patients' function and quality of life on both the inpatient side and the outpatient. I've heard of folks sort of describe cancer rehabilitation as really being all-encompassing, meaning it can be preventative, it can be restorative, supportive, and pallid, depending on where people are. And, you know, as I alluded to, at the opening, you know, treatments for cancer have really, you know, become advanced and there's, you know, unbelievable research and seems like a new pharmacologic discovery or FDA approval almost weekly. Many instances of cancer have become essentially chronic diseases and rehabilitation really is about lifestyle modification and if you could speak to that, that would be great. Yeah, no, no. The technology now, particularly the biologic therapies, the immune checkpoint inhibitors and the number of others where we're still using traditional side-to-talks that came up therapy, but these new agents have been game changers. So you take something like melanoma, which used to have been once it was metastatic, a very quick death sentence within a few months. Now we're using these immune checkpoint inhibitors, which have their own evils associated with them. But I've seen these patients go on for several years in some cases with brain met, spine met and really being quite functional until for whatever reason they start failing these immune therapies and there's this continued churn of new immune therapies, new other classes of treatments that are really changing the game. So you're absolutely right. A breast cancer patient with an early stage breast cancer has a 99% five-year survival, it's extremely unlikely that they're going to die of their breast cancer. And a patient who comes in with metastatic cancer diagnosis may do very well for a long period of time, but as you pointed out, they're going to have all sorts of functional impairments as a result of not just the cancer, really it's more about the treatments. Radiation is one of my personal areas of expertise where I get radiation late effects from all cancer types, but mostly head neck and Hodgkin survivors. And we call it the gift that keeps on giving. There is no expiration date to win those that radiation damage is going to stop. It's just a constant drum beat of loss of function despite all of our efforts to try to maintain it and keep maximized their quality of life. I'm always wondering about the families and how we work with the families. So this is something we have been really, these conceptual frameworks, these tracks I described to you are very emblematic of that. So patients come to us to the inpatient side in multiple ways. They're newly diagnosed with the GBM. They may have had a craniotomy in a resection and don't even have the pathology back. So they not only don't really know what they have, they haven't even come close to having a conversation about what it means. There are other patients who've had disease for years and they're nearing the end, but they're denial about it. So there is a huge psychosocial component to cancer, particularly in the inpatient setting where everything needs to happen very quickly. You've got to make a reasonable plan of care for these patients. You want a discharge plan. And the fact that they don't know what's going on with them is a big barrier to that. And there are cases of patients dying in the hospital, patients going back to acute care and dying very quickly. So what we have been trying to do is to one, educate people about the factors, our nurse liaison, for instance, who are going out and selecting these patients, about what factors go into if this is going to be a good admission or not. And when we identify somebody who is likely not going to do well with us, and we have a number of things. What we're working on is using performance status, something called the cronoscopy performance status, where it's well known in the oncology literature that if you have an end just to kind of frame it, it goes from zero dead to 100 normal. And somebody who's a 30 requires acute hospitalization. Somebody who's a 40 is max assist. Somebody who's a 50 is moderate assist. Somebody who's a 60 is is menaceous for the majority of the measures. And we've translated this from oncology speak to rehab speak. And those patients who have low KPSs of 40 and 50 have a huge six month mortality. By huge, I mean 40% of them will be dead if they have metastatic cancer in our setting. And in the oncology literature, it backs that up. They really have about a 50 day median survival for patients who have a KPS of 40 to 50. So what can we do with that? Well, we need to use that sculpt where the patients come. This concept of come to rehab to get stronger for chemo when we know that's not going to happen is not useful. This concept of we don't want them to lose hope. They've got to go to rehab so they have something to focus on. Also, not a terribly good idea and I'll tell you why. There is another huge body of literature in pallid of care. One of the first ones is the temal study of pain in pallid of care doctor at mass general. And she was able to show the patients who got early pallid of care. These are patients with metastatic lung cancer who got early pallid of care versus this regular treatment. They had less depression. They were more functional and guess what? They lived longer. So this idea of us not telling the patient and giving them the supportive services that they need is really debunked by the literature that shows that when the patients are aware and they're getting the proper services, they do better. And I think it's the same thing for rehab. If we have somebody who's failed all of their treatments, they're clearly in the early stages of dying. Do we want to bring them in for a full course of rehabilitation? Probably not. Would we like to bring them in for a short course of rehabilitation to give them the skills, the tools, the training to be safe at home so that their spouse doesn't hurt themselves trying to manage them. I think that's extremely reasonable. So what we're trying to do is sculpt this and use this information, getting back to the families, to start these conversations which are a process, to try to demystify the mystical. So our staff from the NERSLIAs, on the therapist, the attendings, everybody is not afraid of talking to a patient who we know is dying and about setting realistic goals. Now this flies in the face of what happens when a patient's never even met an oncologist and nobody's talked to them. There are a number of barriers to kind of the rosy, clear cut model that I'm trying to produce and we get that, but we're still chipping over at the edges. Also, the acute care hospitals know what the bounce back. They send an inappropriate patient to acute rehab. What's going to happen to that patient? They're going to go back to them and they're going to be putting this patient in the ICU using all these resources inappropriately on them when that all could have been prevented with early conversation. Right, and really, letting the patient and their family really understand what's going on in them in a humane, realistic way. But is it better that you know the patient is in a bad way or is it better to have that patient die in an ICU alone? And I think most of the data supports that that knowledge is really useful to the patient and their families. So we're trying to give it to them. And I couldn't agree with you, and I think to your point, it just highlights the need to get the rehabilitation team involved as early as possible in the process. And then to have that inaction with the oncologist and really the whole oncology team so that everyone is on the same page and the family and the patient most importantly are on the same page with regard to what the goals and expectations are for coming to a rehabilitation facility. Yeah, it couldn't agree more. So knowing that you encounter challenges where your facilities are involved in the care, even at the acute care hospital in terms of that transition of care, what advice would you have for patients or families that might be at a hospital that's in a market where there isn't a physiatrist involved or there isn't a rehab hospital five minutes away. How should they be thinking about advocating for themselves? What should the thought process be? What discussion should they be thinking about having what their attending physician, whether that's an oncologist or a hospitalist, the case manager and so forth? Yeah, so a great question, but I think I need to reframe it a little bit. So for myself to understand it, there's two settings we've been talking about, the inpatient setting and the outpatient setting. So when you're talking about a patient who has an acute illness and needs to go to an inpatient hospital, that decision, I think most of them want to, based on the little bit that they're told about it. There's a lot of rehab hospitals, there's a lot of good rehab hospitals, there's not a lot of rehab hospitals that really have cancer rehab programs, but that is absolutely changing. And I think having that program, it's hard to show how much it helps, but I think it really helps. It's really hard to put your finger on a metric that people look at, you know, acute care discharge is satisfaction with care, that sort of thing. You know, I think we're starting to excel that. But I'd like to transition that question to the outpatient because that's a real, that's an even bigger challenge. There are maybe 50, if I'm being extremely generous, dedicated cancer rehabilitation physicians in the country. There's a lot of people who are interested in it, we have several fellowships now, we're starting to make more of them, but even a lot of those fellows end up not necessarily [BLANK_AUDIO] cancer rehab even though they got training. That being said, it's a very appealing thing to do. Every time I have a resident come work with me, they're like, "My God, I didn't know anything about this. This is great." And I think the reason it's great for the residents is because it's everything you want. I get a resident, you know, I'm a Kessler. So, you know, my last two residents, one going into spinal cord, one going into brain injury. And both of them were like, you know, if I know this was here, I probably would have gone into cancer rehab. But they don't have to really decide because I do a lot of brain injury. I do a lot of spinal cord. Then I'm joke that I'm essentially sports medicine doctor for cancer patients, clicking carrot neuromuscular muscle scale, a little complications, which is the vast majority of what I do for a living. But all of these patients, the vast majority has so many complex interrelated issues that it really takes a special personality to want to go into cancer rehabilitation as a profession. But I think our residents are so good now that a lot of them are really embracing the complexity of these patients. Now, getting a physician's only part of it, right? So, if you send a head net cancer patient to me, I'm going to look very smart. I'm going to make all of these diagnosis. And I'm going to show you all their cranial monodromathees and their dysphagia, their esopherea, their cervical dystonia. They're lymphedine with their shoulder problems. I'm going to list all of that and I'm going to write you a really beautiful note. But by myself, I am absolutely useless in the long-term management of that patient. I need a teen. And that's part of what I've been doing at Select Medical also is I've developed our Revital Cancer Revealitation Program, which basically started with me and a couple other people on a room with yellow post. We now have over a thousand therapists operating in 20-some-on-markets across the country at multiple states. And what this is is a team of PT's, OT's, SLPs, trained in cancer rehabilitation with ongoing education. I spend a tremendous amount on office hours, team meetings, where we present cases and discuss them. So, we're using sort of real-time interactive learning. And we're starting to get some very good results. If I sort of switch gears just for a moment, you know, health care is obviously under a lot of stress right now with the pandemic. We had, you know, health care transformation going on prior to that. And obviously, health care costs have continued to exceed the roast national product and whatnot in terms of, you know, percentage of GDP. And I want to get too technical on the financial side of things. But clearly, I think CMS Medicare and the government is looking to sort of rein in, expenses a little bit. And if we're going to spend more in one area, you know, then it has to come from somewhere else where we have to really be able to demonstrate that there's a value proposition. You know, looking at cancer rehabilitation, looking at an aging, you know, population, if you, you know, looking out 10 years from now, five years from now, and you're maybe somebody, you know, from capital is listening in on this. What are your thoughts on that? And how do we justify the benefits of cancer rehabilitation? Yeah, these are all great questions. That's a, you know, a particularly great question because I think it is the key to our survival. So I'll start with what we're doing on the outpatient sites first because that's, you know, pretty well fleshed out. So as the world is moving to, you know, quality care as opposed to fee for service, one of the programs is called the OCM, the oncology care model. And this is one of those Medicare demonstration projects trying to minimize the cost of oncology care. And there are several spheres that they're looking at. Among those are emergency room visits, hospitalizations, maintaining, keeping a patient on their, their therapy, patients perception of care, and a variety of other things. So we have very deliberately sculpted our messaging, sculpted our research, sculpted our efforts to trying to deliver on those value propositions. And working with the outpatient physician groups that are subscribed to the oncology care model, I tell you what they love us. And the whole idea, and again, this is largely therapy based, but I consider this all of rehab and the physician and integral part of it because we have different skill sets to supplement it. But the idea is patients show up, cancer patients. The number one thing they complain of, not paid, it's fatigue, right? So PT's and OTs, physical therapists, occupational therapists, are the masters of helping not only treat with deep, but manage fatigue. What's me as a physician have told you that it's not anemia and it's not electrolyte abnormality, it's not this and it's not that. I don't have any other treatments, I can put them on a stimulant. But the truth is, the most effective thing is energy conservation, progressive aerobic activity and all of those things that need to be done. In the context of a patient who might have arthritis and other issues, you need a good therapist to be able to navigate that quack mark because it is a challenge in these patients. You need them backed up by physicians. And in doing that, we believe that we can keep these patients out of the emergency room out of the hospital. We are absolutely trying to demonstrate to affect and demonstrate the value propositions of cancer rehabilitation across the board. And what you were saying about pain, I'll even let alleviating pain, pain is exhausting. Oh, absolutely, absolutely. That's the second biggest reason for cancer patients. And you know, we're not going to take care of your metastatic bone pain with therapy. But a lot of the pain these patients get is musculoskeletal stuff that's been that's been dying and been worsened by the cancer treatment, but can still land them up in the hospital. I know that just the recovery from a chemo treatment, from a single chemo treatment is physically exhausting and you end up laying around doing nothing. And then your muscles get weaker. And so when they do stand up, you don't have the strength to do things. So you're at the risk of falls and, you know, absolutely. And what we do know for patients before cancer during their treatment and after their treatment is activity is critical. And if we could make activity a pill, right, we get a Nobel Prize and we make billions and billions of dollars because the effect of it is that large. It's not a trivial effect. The problem is that not everybody wants to do it. Not everybody believes that it, but what they do, the effects could really be quite remarkable. It speeds up your recovery. I would think in some cases and just make sure life easier in the short or long term. Absolutely. So we want to thank you for spending your time with us today, Dr. Stolman. Thank you. Thanks, Bob. Thanks for listening to Medical Rehab Matters, a podcast by the American Medical Rehabilitation Providers Association. AMRPA would like to thank podcast sponsor Mercer Aputics for its support, as well as their Golden Platinum Association sponsors. Our Platinum sponsors are Bioness, Casa Collina Hospital and Centers for Healthcare and Select Medical. Our Gold sponsors are JFK Johnson Rehabilitation Institute, Moss Rehab and the Center for Improvement and Health Care Quality. You can learn more about Medical Rehabilitation at AMRPA.org.