Discussion on Cancer Rehabilitation Early Career and Fellowship with Dr. Ekta Gupta
Dr. Klein is a PGY4 resident physician in the Stanford PM&R program, and is vice president of the AAPM&R PHiT (Physiatrist in Training) Council.
Dr. Gupta is an assistant professor of PM&R at UT MD Anderson Cancer Center and serves as co-secretary of the Cancer Rehabilitation Community Network. She is also presenting in The Physiatrist’s Role in Cancer Recovery: Helping Patients With Cancer-Distinct Impairments preconference course at the AAPM&R 2017 Annual Assembly.
Dr. Klein: Do you have any general comments on starting a career in cancer rehabilitation or the fellowship?
Dr. Gupta: In terms of being a resident, it depends on your exposure as well as interests. I was lucky to have the opportunity to shadow at MD Anderson when I was a resident. MD Anderson has an acute inpatient cancer rehab unit, which is unique, because it's the only one in the country. We get to work with many debilitated patients that may not necessarily fit into the 60% rule and diagnoses required for admission to an acute inpatient rehab unit. For someone who is training, it's important to see the sickest of the sick in terms of management and care, even if you don’t see that on your everyday practice. With this exposure, you understand what could occur, so you know how to help improve the strength, quality of life and function for those patients who have lasting effects from cancer or its treatments, like steroid myopathy, lymphedema, and graft versus host disease. Saying that, it is not necessary to see cancer patients in your current residency to pursue it as a career. Having a desire to treat cancer patients is the most important.
I went straight from residency into my job, and I have a huge advantage of having experienced partners that are always willing to impart advice and share knowledge regarding the management of our cancer patients. The fellowship provides a comprehensive experience in terms of learning about different types of cancer and following impairments and disabilities. During fellowship, you have lectures to learn about prognosis, treatments, and related side effects that are ongoing in all areas of oncology. The oncology field is constantly changing, and it is often different than what we learned in medical school. Most PM&R residents lack real exposure to oncology. If you can devote that year to fellowship, you learn about the impact of treatment on prognosis, and how the disease and side effects play a big part in your patient’s function and quality of life. You learn when it’s appropriate to do an injection that we may not think twice about in a general population. You also learn to predict the level of return of function we expect for these patients from experts in the field. That said, treatments are always changing, there’s always new clinical trials out there, so you’re constantly learning on the job as well.
Dr. Klein: What inspired you to work in cancer rehab?
Dr. Gupta: I always had an interest in cancer and its effects. I'm from Houston, and I had the opportunity to do a summer research internship at UT MD Anderson in both college and in medical school. I fell in love with PM&R in my 4th year of medical school at Northwestern. When I returned to Baylor in Houston for residency, one of my co-residents the year above me told me about cancer rehabilitation and fellowship opportunities. When I realized it was an option, I was very intrigued and wanted to pursue it. I was interested to learn about the difference we made in the cancer population.
Dr. Klein: What do you find to be most satisfying about what you’re doing?
Dr. Gupta: I really enjoy working on our acute inpatient rehab unit. As many of you know, the inpatient unit allows us to optimize medications, function, quality of life, and the transition to home in an inpatient environment. An interdisciplinary team with physical, occupational and speech therapists, nurses, psychologists, case managers, and social workers allows us to really make an impact on how patients adjust to their diagnosis, treatment, and side effects of cancer. It’s not always a happy ending; there are some patients who have to transfer back to primary medical teams for acute medical management and some patients who pass away. However, I’ve also had it the other way around. For some, I really wasn’t sure how they would adjust to life outside of the unit, and they come back to my outpatient clinic showing how we helped them reach their functional needs. They have returned to work, or they’re successful in what they want to be or do. It’s very gratifying to see that. In this patient population, society says “oh you have cancer, it’s the end of your life,” but it’s truly not. There’s a lot to live for, adjust to, and be happy with. I’m honored to help these patients achieve this.
Dr. Klein: What makes cancer rehab unique and what are some services offered that are unique to the specialty?
Dr. Gupta: Cancer rehab includes every rehab diagnosis we learn about in training, with an added component of dynamic change with cancer. Our goal is to optimize function and quality of life in patients dealing with the effects of the cancer and its treatments including chemotherapy, immunotherapy, and other investigational drugs. Hopefully we can reduce side effects causing physical and mental issues, and increase function and strength. There are some cancers that go into remission or there's no evidence of disease, and others that are always evolving with new metastases or effects. While we see spinal cord injury and deficits from brain tumors such as spastic hemiparesis, our rehabilitation treatment plans can differ compared to traumatic injuries. Through experience, I have realized that the recovery is different in terms of the return of function and spasticity management.
There is a variety of unique services. To name a few, lymphedema management is an integral part of care, and we work very closely with physical and occupational therapy to help diagnose, treat, and manage this. Head and neck cancers and their treatments cause very specific impairments, and we work closely with speech therapy on improving function after these. There is also complexity behind managing rehabilitation of patients with liquid tumors. Cancer-related fatigue is prominent, and rehabilitation has been shown to have a significant impact on improving this side effect. Thrombocytopenia affects the level of resistance and strengthening exercises that therapists are able to perform with patients. As a cancer physiatrist, you have to have a comprehensive view of the patient’s cancer, treatment-related side effects, medical comorbidities, and then come up with an optimal treatment plan.
Dr. Klein: Where do you think this subspecialty is going?
Dr. Gupta: It’s growing and it’s growing quickly. There are many avenues to explore and relationships to build. Certain oncologists and surgeons recognize the impact of cancer rehabilitation more than others, and I’m hoping we will be able to develop relationships with all oncologists and surgeons to truly optimize patient care. Nationally, steps are being taken by prominent members of the field to develop relationships with organizations and communities as well.
By educating the providers, we hope to impact the amount and quality of patient information that's out there. It’s a simultaneous process. A major focus of the AAPM&R Cancer Rehab Community Network is both patient and provider education, focusing on avenues to explain our role in the cancer continuum.
Research is key. AAPM&R as well as ACRM (American Congress of Rehabilitation Medicine) are doing many projects focusing on research and development in different areas of cancer rehabilitation. There’s work on a Cochrane review looking at head and neck cancers and the physiatrist’s role. Our community network is also doing a survey to see how cancer rehabilitation is practiced, and there is a trial involving centers around the U.S. looking at functional metrics that can hopefully be used to standardize impact of care in the future. In addition, I know that most cancer rehabilitation physiatrists do research daily at their institutions to help advance our field.
Dr. Klein: What kinds of settings have people worked in once they’ve gotten training in cancer rehab?
Dr. Gupta: There are several opportunities with both academic and private practice options. MD Anderson’s fellowship often focuses on teaching a comprehensive understanding to developing a cancer rehabilitation practice, and many of our prior fellows have started new programs at academic institutions. There is also a definite need for private practice cancer physiatrists. Some residents with interventional exposure go on to have a procedural practice. Some go into long-term acute care or work in nursing facilities, where a large amount of cancer patients are often sent to for strengthening and return of function with cancer-related fatigue and other impairments. There’s quite a variety of avenues. We need to realize that these patients are there, and we need to figure out how to get them access to care in each setting.
Dr. Klein: What do you think are some character traits in an excellent cancer rehab practitioner?
Dr. Gupta: Patience and integrity are quite important, as well as compassion. You make difficult decisions for patients suffering from cancer and its effects, and sometimes it’s not what a patient wants to hear. A strong knowledge base is key as well. Because of the evolving nature of cancer, we have to remember treatment and functional plans are different than stroke or traumatic spinal cord injury. Sometimes optimizing a patient’s care at a lower level of function but the opportunity to be at home with their family equates to an improved quality of life, rather than staying in the acute inpatient rehabilitation unit despite functional potential.
Dr. Klein: For areas that do not have cancer rehab, how do you envision it fitting in and being developed with palliative and oncology services?
Dr. Gupta: In terms of starting a practice in areas that do not yet have formal cancer rehab, there’s a need everywhere. I always tell people that we work as an interdisciplinary team. When oncologists see what we do, they often say they didn’t know there was a physician who worked with such a team that could provide these services for their patients. We provide components of care to manage symptoms, enhance quality of life, improve function, and optimize strength.
We have patients that are going into hospice, who are DNR/DNI, that still benefit with rehabilitation. Choosing to proceed to comfort measures only doesn’t equate to not having rehabilitation to optimize your care, to be happy during that time period, and be functional and do what you want to do.
Palliative and rehabilitation have a significant crossover. We have providers that are double boarded in palliative and cancer rehab medicine. They're able to use their skills to improve the quality of life and symptom management. At MD Anderson, our department consists of palliative, rehabilitation, and integrated medicine. Working together, we realize the importance of rehabilitation for palliative patients. The techniques that we learn as rehabilitation physicians can be used to assist at end of life.
Dr. Klein: How would a resident who wants to pursue cancer rehab fellowship explore it further and optimize getting into a fellowship or position they want?
Dr. Gupta: Every fellowship wants to see that the resident has an interest in cancer rehabilitation and has a sense of where the field is heading. It’s not always easy to obtain hands-on experience, partially because of diagnoses qualifying for acute rehabilitation, but also due to lack of referrals as not everyone realizes how we impact care. Some residents are reaching out to oncologists on their own during residency and saying, “this patient population has needs that we can assist with,” and are offering to give talks on PM&R and cancer rehab.
If you have the option of doing an away rotation, I would consider this if you really don’t have exposure in residency. Doing other things on your own, like case reports of patients you see, and literature reviews can definitely make an impact. Genuine interest to impact the care provided to the cancer population is what we are all looking for. A great resource to find available fellowship opportunities is the AAPM&R Job and Fellowship Board.
Dr. Klein: Any other thoughts on the fellowship, for example, comparing palliative and cancer rehab fellowships?
Dr. Gupta: Our fellows in the program always say they wouldn’t trade the experience for anything. The people that do the fellowship understand how much there is to learn and appreciate the knowledge that they've gained. I know that one goal we are working toward is accreditation of the cancer rehab fellowship.
Between cancer rehabilitation and palliative, there are some differences. With your background of rehabilitation, you can bring the added component of functional improvement to your palliative patients. I do know a few people around the country that are double boarded and have practices that combine this care. However, with only the palliative fellowship, you may see a different patient population. There are the stage 1 or stage 2 cancer patients that are not always seen by palliative, but are seen by cancer rehab specialists. The management, prognosis, and the way you help those patients and their function and quality-of-life is different.
Dr. Klein: Any other recommendations for residents who have an interest in cancer rehab that we haven't touched on yet, maybe that I haven’t asked about?
Dr. Gupta: What really helped for me as a resident was having a mentor of whom I could ask questions. From my experience, everyone is willing to mentor and help teach about cancer rehabilitation. As a resident, I would reach out to your residency director or prior residents that may know someone you can then talk to about cancer rehabilitation.
Speaking as co-secretary of the AAPM&R Cancer Rehab Community Network, we have sub-groups where there are a lot of opportunities to become involved. Residents can assist with research as well as development and growth of the field. Be involved with a national organization. This helps create relationships with practicing cancer rehabilitation physicians, helps you learn more about leadership opportunities, and helps make a difference as a resident for patient care.
Dr. Klein: What are some good resources?
Dr. Gupta: As above, AAPM&R, ACRM, and AAP have a lot of resources. There’s a lot of research to be done in our field. AAPM&R and ACRM have formal groups and are looking for residents to assist with research projects. There is a new cancer rehabilitation research fund recently launched by the Foundation for PM&R. Fundraising is in process, initiated by Drs. Gail Gamble and Michael Stubblefield. This will be a great venue for young investigators to find funding to work on their research projects.
AAPM&R’s journal, PM&R, also recently released a new cancer supplement, Integrating Rehabilitation Into the Cancer Care Continuum. At the AAPM&R Annual Assembly, there is The Physiatrist’s Role in Cancer Recovery: Helping Patients With Cancer-Distinct Impairments preconference course, which will have practical teaching on how to apply cancer rehab in your everyday practice to improve cancer-distinct impairments. There are also talks that happen every day:
- The Physiatrist’s Role in Cancer Recovery: Helping Patients With Cancer-Distinct Impairments
Wednesday, October 11 | 8 am-5 pm
Course Directors: Jennifer A. Baima, MD, FAAPMR and Mary M. Vargo, MD, FAAPMR; Faculty: Andrea L. Cheville, MD, FAAPMR; Sara A. Christensen Holz, MD; Jack B. Fu, MD, FAAPMR; Theresa Gillis, MD; Ekta Gupta, MD, FAAPMR; Nancy A. Hutchison, MD, FAAPMR; Ashish Khanna, MD; R. Samuel Mayer, MD, FAAPMR; Vishwa S. Raj, MD, FAAPMR; Julie K. Silver, MD, FAAPMR; Michael D. Stubblefield, MD, FAAPMR; Mary M. Vargo, MD, FAAPMR; Yevgeniya Dvorkin Wininger, MD; Eric M. Wisotzky, MD, FAAPMR; Rajesh Yadav, MD, FAAPMR
- Controversies in Imaging: Regenerative Medicine, Musculoskeletal, Neuro- and Cancer Rehabilitation
Wednesday, October 11 | 8 am-5 pm
Course Directors: Andre Panagos, MD, MSc, FAAPMR and Marwa Ahmed, MD, MS; Faculty: Yvonne Lui, MD; David Harshfield, MD; Rahul Desai, MD; Mary Jesse, MD; Colin Strickland, MD; Michael Stubblefield, MD, FAAPMR; Jeff Strakowski, MD, FAAPMR
- Identification, Evaluation, and Rehabilitation of Neuromuscular, Musculoskeletal, Pain, and Functional Disorders in Head and Neck Cancer
Thursday, October 12 | 2 pm-3:30 pm
Michael D. Stubblefield, MD, FAAPMR, Barbara Murphy, MD, Kenneth Niermann, MD
- Innovations to Improve the Cancer Rehabilitation Outcome Assessment, Promote Referrals, and Build an Evidence Base: A Guide to Pragmatic Implementation
Friday, October 13 | 4 pm-5:30 pm
Jack Fu, MD, FAAPMR, David Zucker, MD, PhD, FAAPMR, Andrea Cheville, MD, MSCE, FAAPMR, Richard Moser, PhD NIH, Samman Shahpar, MD, FAAPMR
Thank you, Dr. Gupta!