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. Author manuscript; available in PMC: 2021 Mar 17.
Published in final edited form as: PM R. 2019 Sep 9;12(2):180–185. doi: 10.1002/pmrj.12196

Training and Practice Patterns in Cancer Rehabilitation: A Survey of Physiatrists Specializing in Oncology Care

Raman Sharma 1, Diana Molinares-Mejia 2, Ashish Khanna 3, Susan Maltser 4, Lisa Ruppert 5, Sarah Wittry 6, Ryan Murphy 7, Anne Felicia Ambrose 8, Julie K Silver 9
PMCID: PMC7967832  NIHMSID: NIHMS1638309  PMID: 31140751

Abstract

Background:

Cancer rehabilitation is an integral part of the continuum of care for survivors. Due to the increasing number of survivors, physiatrists commonly see cancer patients in their general practices. Essential to guiding the field is to understand the current training and practice patterns of cancer rehabilitation physicians.

Objectives:

To assess current trends in training and practice for cancer rehabilitation physicians, including the level of burnout among providers in this field.

Design:

Cross-sectional descriptive survey study.

Setting:

Online survey.

Participants:

American physicians who are affiliated with the Cancer Rehabilitation Physician Consortium (CRPC) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R). The CRPC is a group of cancer rehabilitation providers (both fellowship-trained and not fellowship-trained) with the mission of furthering cancer rehabilitation medicine through education, research, and networking.

Methods:

All CRPC physicians were invited to complete a voluntary and anonymous 43-question online survey. The survey was conceived by a group of eight experts interested in providing additional information to the current literature regarding the training and practice in the cancer rehabilitation field.

Main Outcome Measurements:

Training, practice, opioid prescribing, and professional support.

Results:

Thirty-seven of 50 physicians participated (response rate = 74%). Respondents were from various states, the three most common being New York (16%, n = 6), Texas (16%, n = 6), and Massachusetts (11%, n = 4). About 57% (n = 21) of the respondents were employed in an academic medical center and 73% (n = 27) reported their primary departmental affiliation was Physical Medicine and Rehabilitation (PM&R). Approximately 78% (n = 29) credited mentorship early in training for their interest in the field. More than half (54%, n = 20) either strongly agreed or agreed that cancer rehabilitation fellowship training is necessary for graduating physiatrists who plan to treat oncology patients/survivors. National PM&R meetings were the primary source of continuing education for 86% (n = 31). Sixty-five percent (n = 24), strongly agreed or agreed that cancer rehabilitation physiatrists should know how to prescribe opioids, and 35% (n = 13) reported prescribing them when appropriate. About 54% (n = 20) rated their level of burnout as low or very low, and more than half (51%, n = 19) believed their burnout level was lower than physiatrists treating other rehabilitation populations.

Conclusions:

Cancer rehabilitation is a growing subspecialty in PM&R, and most physiatrists in general practice will treat many survivors—often for neurologic or musculoskeletal impairments related to cancer or its treatment. Cancer rehabilitation physicians perceive that they have relatively low levels of burnout, and early mentorship and fellowship training is beneficial. Professional conferences and mentorship are a primary source for continuing education.

Introduction

Currently, there are more than 15.5 million cancer survivors in the United States and more than 40% of people born today will develop some type of cancer during their lifetime.1,2 To put this in perspective, the total number of cancer survivors today is greater than the combined number of spinal cord injury (288 000),3 traumatic brain injury (5.3 million),4 and stroke (6.8 million)5 patient populations. As oncology-directed treatment modalities advance, overall survivorship is expected to continue to increase, with number of survivors expected to exceed 20 million by 2026.6 As these survival rates continue to increase, it is important for all clinicians to not only be aware of potential impairments that may arise as a direct result of a tumor or its oncologic management, but to understand how to apply rehabilitation principles to this population.7–9 This topic is of great interest to physiatrists in general, as the majority of them are regularly caring for cancer survivors who often have problems related to oncology-directed treatment (eg, shoulder adhesive capsulitis in patients with a history of breast, lung, or head and neck cancer).10,11 There is a growing group of early career physiatrists who are training in cancer rehabilitation. Furthermore, there is a larger group of physiatrists involved in clinical practice, medical education (chairpersons, program directors, deans), and health care administration (medical directors, chief medical officers, chief executive officers), who also play an important role in the continuum of care for cancer survivors. In addition, it is essential to understand the comfort level that physiatrists have when treating issues prevalent to the oncological patient population, such as opioid management.12 Opioid prescription may be one of the perceived barriers in caring for cancer survivors.

Not surprisingly, there is a tremendous need for physiatrists who specialize in cancer, and as such, it is important for the field of PM&R to consider its commitment to the growth and accreditation of this specialty. There are currently five cancer rehabilitation fellowship training programs in the United States and two additional programs are anticipated to start in 2020. The first of these programs began in 2007, and all of them are 1 year in duration.13 Despite the continuous growth of the field, noncancer rehabilitation providers will continue to encounter cancer survivors as part of their general or specialty practice. Therefore, the importance of education in cancer rehabilitation principles during residency training is crucial, which was previously highlighted in the literature.14 There is also clear need for increased research in the field of cancer rehabilitation.15–17 One third of the total cancer rehabilitation reports were published within the past 2 years, with less than 20 reports published annually until 2016 (n = 25) and 2017 (n = 31).18,19

Members of the Cancer Rehabilitation Physician Consortium (CRPC), as a group of experts, undertook this survey study with the goal of providing physiatrists with more information about the current cancer-focused landscape in PM&R training and practice, national and institutional support, as well as the level of burn out.

Methods

A 43-question survey was sent to U.S. physicians identified by the CRPC and completed by 37 of 50 (74% response rate). The CRPC is part of the American Academy of Physical Medicine and Rehabilitation (AAPM&R). The survey was emailed on three separate dates from July through September 2018. Participation was voluntary and anonymous. This study was approved by the Burke Rehabilitation Hospital, Montefiore Health System, Albert Einstein College of Medicine Institutional Review Board on June 27, 2018.

The survey questions were created, voted upon, and selected by members of the Cancer Rehabilitation Task Force of the CRPC with a goal of covering topics most relevant to current practice. Questions were further grouped into the following categories1: Demographics, Training, and Practice2; Opioid Prescribing; and3 Professional Support. Survey answer formats consisted of either a free textbox or a psychometric Likert scale to gauge the array of responses. Descriptive analysis and statistics were tallied and reported.

Results

Demographics, Training, and Practice

Of the 37 respondents, approximately half were women (n = 19) and half were men (n = 18). Geographical location of practice was diverse, although the northeast region of the United States (New York, Massachusetts, New Jersey, District of Columbia, Maryland, Virginia) accounted for almost half of all responses (49%, n = 18) and the three most represented states were New York (n = 6), Texas (n = 6), and Massachusetts (n = 4). Thirty-five (95%) had graduated from a PM&R residency and two (5%) were still in residency training. Approximately half (n = 18) had completed or were in fellowship training. About 61% (n = 11) of those with fellowship training, completed a cancer rehabilitation fellowship. Of all respondents, 54% (n = 20) either strongly agreed or agreed that a cancer rehabilitation fellowship is necessary for graduating physiatrists who plan to treat oncology patients/survivors, 19% (n = 7) were neutral, and 22% (n = 8) disagreed. Other recommended fellowships included palliative care and hospice fellowship (53%, n = 19) or a pain medicine fellowship (25%, n = 8). About 78% (n = 29) of all participants either strongly agreed or agreed that formal Accreditation Council for Graduate Medical Education (ACGME) approval for cancer rehabilitation fellowships was important to obtain. Seventy-eight percent (n = 29) strongly agreed or agreed that identifying a mentor early in their training helped them advance into this field. National PM&R meetings were the primary source of continuing education for 86% (n = 31) of the respondents.

There were more early career physicians (68%, n = 25) than mid- and late career (32%, n = 12). Most respondents (60%, n = 21) practiced in an academic medical center. Others worked at National Cancer Institute (NCI) designated centers, rehabilitation hospitals, and ambulatory care practices. Notably, none of the cancer rehabilitation physicians reported working in private practice. The highest number of respondents (41%, n = 15) reported practicing in an outpatient environment, and more than half (51%, n = 19) said they focus primarily on clinical care with only one physiatrist (3%) reporting being a full-time researcher (Figure 1).

Figure 1.

Figure 1.

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Types of practices for current Cancer Rehabilitation Physiatrists. x-axis = Percent of Cancer Rehabilitation Physiatrists. y-axis = Practice Type.

About 73% (n = 27) reported their primary departmental affiliation was PM&R, with the next largest departmental affiliations being departments of neurology or palliative care (8%, n = 3 each). More than half (51%, n = 19) reported spending the majority of their time (76%−100%) on the clinical care of cancer patients (Figure 2). About 75.7% (n = 28) replied that they spend less than 25% of their time on research related to cancer patients (Figure 3). Thirty-five percent (n = 13) were members of their institution’s cancer committee (multidisciplinary group of leaders that promote patient quality care throughout the cancer continuum), whereas 32% (n = 12) had a cancer committee but were not members.

Figure 2.

Figure 2.

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Percentage of time spent on the clinical care of cancer patients. None (dark blue), less than 25% (orange), 26%–50% (gray), 51%–75% (yellow), 76%–100% (sky blue).

Figure 3.

Figure 3.

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Percentage of time spent on research related to cancer patients. None (dark blue), less than 25% (orange), 26%–50% (gray), 51%–75% (yellow), 76%–100% (sky blue).

Opioid Prescribing

Of the 37 respondents, 65% (n = 24) strongly agreed or agreed that cancer rehabilitation physiatrists should be well informed about how to prescribe opioids and that they should prescribe them when appropriate. Thirty-five percent (n = 13) strongly agreed or agreed that they prescribe opioids for cancer patients in their clinical setting, whereas 51% (n = 19) reported that they do not. Although 41% (n = 15) stated they were comfortable overseeing the long-term opioid pain management plan for their patient, 54% (n = 20) reported they believe complex opioid management is better suited for palliative care providers. Fifty-seven percent (n = 21) of respondents refer their patients to palliative care services once they have exhausted all other pain management options.

Professional Support

About 54% (n = 20) of respondents rated their level of burnout as low or very low, and more than half (51%, n = 19) believed that their burnout level was lower than physiatrists treating other rehabilitation patient populations. Sixty-two percent (n = 23) of participants believe that oncology health care professionals lack information about cancer rehabilitation, and furthermore, 68% (n = 25) believe that the oncology team may not fully appreciate how patients can benefit from cancer rehabilitation. As outpatient referrals to cancer rehabilitation increase, 68% (n = 25) of respondents either strongly agreed or agreed that oncology professionals were receptive to referring patients. Eighty-six percent (n = 32) of respondents reported that referring oncology teams are accepting of their professional opinion, even if it includes no rehab (eg, hospice care). Regarding palliative care, almost half of the participants (48%, n = 18) stated that patients referred for cancer rehabilitation are not concomitantly followed by the palliative medicine team. The group appeared divided on the decision to refer patients to palliative care when they identified other possible sources of distress (psychological, existential, and relational) with 49% (n = 18) in favor of referral and 32% (n = 12) not in favor. In terms of prehabilitation, 68% (n = 25) strongly agreed or agreed that oncology teams were more receptive to referring patients if the services were embedded and onsite.

Most respondents were members of the AAPM&R (94%, n = 34), followed by the Association of Academic Physiatrists (AAP) (64%, n = 23), and the American Congress of Rehabilitation Medicine (ACRM) (44%. n = 16). The participants reported their perception on the medical society support of professional growth of cancer rehabilitation physiatrists in this order: ACRM, 95% (n = 35); AAPM&R, 65% (n = 24); and AAP, 35% (n = 13). In contrast, they also reported attrition from the professional societies and that memberships have not been constant. The proportion of respondents who reported they were previously a member of a medical society but are no longer active is as follows: ACRM, 61% (n = 11/18); AAP, 50% (n = 9/18); and AAPM&R, 39% (n = 7/18). The primary reason for no longer remaining a member of the societies was financial, with 41% (n = 12/29) stating membership was too expensive to maintain. Another 14% (n = 4/29) reported withdrawing their membership because they thought there was not enough support for cancer rehabilitation physicians.

Discussion

There is an extraordinary unmet need for cancer rehabilitation care.20–22 This study conducted by members of the CRPC focused on subspecialty training, practice demographics, opioid prescribing patterns, and support from professional oncologic health care professionals and PM&R societies.

Over half (54%, n = 20) of respondents believed that cancer rehabilitation fellowships were necessary, with about one-quarter (27%, n = 10) disagreeing. Early career participants were more likely to agree. This is consistent with previous studies in which recent graduates of cancer rehabilitation fellowship programs strongly believed that their formal fellowship training prepared them to meet the rehabilitation needs of oncology patients.23,24 In contrast, physiatrists who finished training more than a decade ago did not have the available option of cancer rehabilitation fellowship training, which could have impacted their view toward fellowship. There was relative consensus regarding career mentorship, with nearly 80% (n = 29) reporting that finding a mentor early in their training helped them advance into this field.

Currently there is no standardized curriculum for fellowship training or certifying examination. Cancer rehabilitation education largely occurs through mentorship and at national professional society meetings (86%, n = 31). There was consensus that more dedicated cancer rehabilitation fellowships should be developed and be recognized by the ACGME (78%, n = 29). In this survey, most respondents who were fellowship trained completed their training in a dedicated cancer rehabilitation fellowship (61%, n = 11); however, respondents reported that fellowship training in other areas could also be beneficial if there was not a cancer rehabilitation position available. The most common alternative fellowship recommendations were palliative care (53%, n = 19) and pain medicine (25%, n = 9).

The respondents reported that their practices were largely focused in academic medical centers (60%, n = 21), with the greatest areas of concentration of practitioners (49%, n = 18) being the northeast and mid-Atlantic regions. Most practitioners described themselves as early career physicians (68%, n = 25) followed by mid- and late-career (32%, n = 12), a trend expected to continue, with increasing numbers of available fellowship programs. In the aforementioned Yadav et al study, half of recent fellowship graduates stated that they moved into positions created specifically for them, and that the majority of graduates were able to able to find jobs in which oncology patients made up 50% or more of their practice.23

About 86% (n = 31) of respondents reported that much of their continuing education comes from professional society conferences, the role of these organizations is particularly important to the field. Respondents reported that the ACRM provided the greatest level of support, but this was also the society that had the most attrition. Notably, regarding attrition, the primary factor was the cost of maintaining a membership. Nearly all of the respondents were active members of the AAPM&R and most were also members of the AAP. Less than half were active members of the ACRM. Of interest, the ACRM is interdisciplinary, whereas the other two societies, AAPM&R and AAP, are both physiatry focused.

Future growth of the field and society commitment will be necessary, as survival rates increase and the demand for cancer rehabilitation practitioners grows.25 Institutional support seemed to be an area with opportunity for multidisciplinary collaboration and growth.26 Oncology professionals are generally thought to be receptive to referring patients for rehabilitation care, particularly when the services are embedded onsite. The majority of respondents indicated that there is an opportunity to provide more information to them about the benefits, and this may be accomplished by providing them with literature that supports clinical and wellness interventions, especially studies that highlight the benefits in optimizing tolerance to upcoming surgery or adjuvant treatments, minimizing toxicity, and improving outcomes.27

Opinions on use of opioids varied among respondents. Just over one-third (35%, n = 13) prescribe opioids in their practices, whereas more than half (51%, n = 19) stated that they do not prescribe opioids in this population—primarily citing they believe that palliative care providers are more experienced to manage this. Respondents who were strongly affiliated with cancer centers were more comfortable with prescribing opioids than respondents who were in private practice and/or did not have a close affiliation. Despite variations in prescribing practices, approximately two-thirds (65%, n = 24) of respondents identified understanding opioid management as an important component of cancer rehabilitation training.

Physician burnout is on the rise, and in one study by Shanafelt et al found that PM&R was ranked as third in burnout among all specialties.28 About 54% (n = 20) of the survey participants rated their level of burnout as low or very low, and more than half (51%, n = 19) believed that their burnout level was lower than physiatrists treating other rehabilitation populations. Silver and Bhatnagar found that physicians valued mission-driven work and suggested that PM&R focus on this in an effort to combat burnout.29 This information may be encouraging to students and early career physicians who are considering entering the subspecialty.

Study Limitations

Limitations to this study include the sample, which was limited in size, it only included physicians who have formally self-identified as having an interest in cancer rehabilitation and who are members of the CRPC group. Although this study includes the largest number of participating cancer rehabilitation physiatrists, there were invitees who did not participate in the survey. Limitations of the research instrument included internet access to complete the survey as there was no paper option available for the respondents.

Conclusion

As these cancer survival rates continue to increase, it is important for clinicians to not only be aware of potential impairments that may arise as a direct result of cancer or its oncologic management, but to understand how to apply rehabilitation principles to this population. This study conducted by members of the CRPC highlights the importance of cancer rehabilitation subspecialty training and mentorship for those physiatrists who wish to care for oncologic patients. This study also highlights the importance of understanding opioid management as an aspect of treatment. Despite the challenges and complexities of the oncologic population, this study shows lower rates of physician burnout in comparison to other subspecialties within PM&R.

Acknowledgments

The authors would like to thank Sean Smith, MD, Medical Director, Cancer Rehabilitation Program at The University of Michigan for his assistance with this survey study. The authors would like to thank the Cancer Rehabilitation Physician Consortium of the American Academy of Physical Medicine and Rehabilitation for their assistance with this survey study.

The authors would like to thank Masood Shariff, MD, Postdoctoral Fellow at Lincoln Hospital, New York City Health and Hospitals, for his assistance with generating figures for the manuscript.

Footnotes

Disclosure

Disclosure: None.

Disclosure: Grant, Memorial Sloan Kettering Cancer Center Support Grant/Core Grant (P30 CA008748).

Contributor Information

Raman Sharma, Department of Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital, White Plains, NY. Address correspondence to: Raman Sharma, MD, Department of Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital, 785 Mamaroneck Ave. White Plains, NY 10605.

Diana Molinares-Mejia, Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.

Ashish Khanna, Department of Cancer Rehabilitation, Kessler Institute for Rehabilitation & ReVital Program, West Orange, NJ.

Susan Maltser, Department of Cancer Rehabilitation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.

Lisa Ruppert, Department of Rehabilitation Medicine, Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical College, New York, NY.

Sarah Wittry, Department of Rehabilitation Medicine, University of Washington, Seattle, WA.

Ryan Murphy, Physical Medicine & Rehabilitation Services, Valley Hospital & Valley Medical Group, Ridgewood, NJ.

Anne Felicia Ambrose, Department of Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital, White Plains, NY.

Julie K. Silver, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA; Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Boston, MA; and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.

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