Commentary on “Oncologists' and Physiatrists' Attitudes Regarding Rehabilitation for Patients With Advanced Cancer”

Abstract

The provocative study by Spill et al [1] in this issue of PM&R serves to highlight a number of potential barriers faced by patients with advanced cancer receiving rehabilitation services that result from differing attitudes between rehabilitation physicians and medical oncologists. As discussed in the article, these potential barriers may not be trivial. Under certain conditions, they have the potential to create conflict between rehabilitation physicians and medical oncologists, thus compromising patient care. Many of the conclusions from this study serve to back up many of my own anecdotal clinical observations and lay bare a number of issues that need to be discussed further if we are to move the field of cancer rehabilitation forward. It is difficult to draw definitive and broad conclusions from a 15-question survey of a few hundredphysiatristsseeing,onaverage,1patientwithadvancedcancerperweekcompared with oncologists who see 60 patients per week. As described in the article, this disparity in the number of cancer patients seen was anticipated and reflects the nature of most rehabilitation medicine practices relative to oncology practices. Some major differences other than the attitudes between the 395 medical oncologists and rehabilitation physicians surveyed were found but not discussed at length in the study. These differences are likely important because they may have an impact on some of the findings. For instance, the average age of the medical oncologists was 53 years, whereas that of the rehabilitation physicians was only 45 years (P .001). Similarly, the number of years since completing practice was 19 for the medical oncologists but only 12 years for the rehabilitation physicians (P .001). This difference in age and time in practice may have affected the observation that medical oncologists are much more likely to refer a patient to inpatient rehabilitation for the emotional or psychological benefit of the patient or the family than rehabilitationphysiciansaretoacceptsuchapatientforinpatientrehabilitationforthesame reasons. The questions referable to these conclusions were prefaced by “In your career to date” for both specialties. Physicians in practice 20 years ago would have seen a time when use and reimbursement of inpatient rehabilitation services were very different from what they are today [2]. A physician in his or her 50s or 60s might have had the luxury, albeit inappropriate, of using such admissions for other than functional reasons 20 years ago. Given the tightening of admission standards for inpatient rehabilitation in today’s environment, such improper use of services has become progressively more difficult because these admissions must be based on legitimate and documented functional impairments. It is not clear from the survey and the way that the question was phrased whether admitting or accepting a patient to acute rehabilitation for the emotional or psychological benefit of the patient or the family represents a historical or contemporary attitude. That being said, as a physician who has worked full-time rehabilitating cancer patients in a large tertiary care cancer center for more than a decade, I will admit to occasionally having had the desire to sendapatienttoinpatientrehabilitationforemotional,psychological,orfunctionalreasons. We all have a strong desire to advocate for the best interest of our patients. So long as we are on solid footing in terms of the primary objective and focus of inpatient rehabilitation, the added benefit of rehabilitation providing hope and focus to a patient who is terminally ill is not necessarily a bad thing. In the Spill et al [1] study, a significant difference in responses between rehabilitation physicians and medical oncologists concerned life expectancy. Rehabilitation physicians