Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we have two Northwestern Medicine Marianjoy Rehabilitation Hospital clinicians for you today in a thought leader panel to discuss and highlight cancer rehab and psych integration. Joining me is Dr. Robin Cohen, she's a Physical Medicine and Rehabilitation specialist; and Dr. Nicolette Bernhardt, she's a board-certified clinical health psychologist.

Doctors, thank you so much for joining us today. And Dr. Cohen, I'd like to start with you. Give us a sort of a setup on the role of physical medicine in cancer rehabilitation, how that contributes to a patient's recovery journey.

Dr Robin L. Cohen: Hello, and thank you. I appreciate the introduction and the first question. It's well-documented and recognized that the majority of individuals living with and beyond cancer experience compromised physical and cognitive function due to cancer treatments and their side effects.

Cancer-related physical and functional impairments are very high. Some data has demonstrated that an average of three impairments can last greater than 10 years after cancer treatment. Many people also are concerned about being a burden to their friends and family. And that burden means being able or needing to rely on family and friends for helping with shopping, homemaking, and just help with stair climbing, even doing basic self-care activities such as dressing, and this is a concern to many patients.

We also know that fitness and quality of life are associated with patient survival. And often, fitness, pain, fatigue, and frailty can influence a person's decision to continue with cancer treatments. These concerns are found in patients regardless of where they are in their cancer journey also can be found across many different types of cancers.

And these are questions and concerns that we could address head on and help patients manage to improve their quality of life, and allow them to continue to engage in cancer treatment, for many years to come if needed. And I think this are critical questions as more patients survive, live with cancer for many more years, and quality of life has become a critical aspect of cancer treatment.

Melanie Cole, MS: And it is such an important aspect of cancer journey, that journey that people take when they are in rehabilitation, when they are going through their treatments, there are so many aspects. And Dr. Cohen, I'd like to stick with you for just a minute. As you've been giving us some examples of the physical challenges that patients often encounter during their rehabilitation, as you said, climbing stairs and putting on clothes, just everyday things, how do you tailor those rehabilitation strategies that you prescribe to meet the individual unique needs of each patient? Speak about that shared decision-making and really those challenges, how you look to each patient and what they are going through.

Dr Robin L. Cohen: I think meeting patients face to face is an important part of understanding more about what challenges patients may be facing in terms of their physical functioning. And, obviously, or maybe not so obviously related to that, is their mental health. And I think it's very important to talk to patients and sit down and focus and ask them pointed questions regarding how they're functioning at home. It's very helpful when patients bring in friends or their spouses. Often those interpersonal communications are very revealing as to what may truly be going on in the home. And so, I think it's very important to address specific needs patients have.

For example, I recently saw a patient that was in to see me for generalized deconditioning. But really, the biggest issue she was having was really her shoulder. And I was able to address that particular concern that the patient had and help connect her to other specialists in the healthcare system to help address her shoulder issue. And then, similarly, and this is where Dr. Bernhardt and I have an outstanding and close working relationship, and people often do not come in talking about anxiety, fear, worry, insomnia, pain. People are very stalwart, and those are hard feelings to bring up to the surface to discuss, I think. And sometimes having a more generalized discussion initially about activity and energy and fatigue and you can kind of get to sleep,. And sometimes that makes it easier to start a conversation about people's emotional state. And that is where I can help identify patients that really would benefit greatly from Dr. Bernhardt's care.

Melanie Cole, MS: Well, there are so many diverse types of cancers and, along with them, such an array of treatments that I can see where the physical challenges really come into play as you've described, like the patient's shoulder. But now, as far as the psychological aspects of cancer, Dr. Bernhardt, as a psychologist, give us some examples of those challenges that patients face, how you help them navigate, because I think it's been underlooked, underappreciated in the past 20 years, but we're now realizing that outcomes really do connect with that quality of life and mental health. And there's such a mental health issue going on today. So, how do you approach those aspects of cancer rehabilitation? And give us some of the strategies you employ to support patients mental health during this whole process.

Dr Nicolette M. Bernhardt: Absolutely. One of the biggest struggles I find is that patients do come in with a variety of different emotional aspects related to their cancer diagnosis and treatment. But the first thing I do is really assess where a patient is in their cancer journey. Are they just, you know, newly diagnosed? So, are they facing this fear that their body's turned against them or that they're going to be facing chemotherapy or radiation or surgery or things that are very life-altering for them? Or are they currently in treatment? So, are there medical issues that they're currently facing? Have they experienced loss due to surgery? Are they struggling managing every day to day life? But there's also those patients that are in survivorship that are also struggling. And I think that's also an area that is often overlooked.

Many of the patients that I see from either referrals from Dr. Cohen or just in my own outpatient oncology practice are patients that are in survivorship that have been kind of lost in the shuffle, that are struggling to recover from all of the emotional and physical aspects that have come from cancer diagnosis through treatment, through survivorship. So really, my goal when working with patients is to see where they're at and to really help them understand how stress reduction can help at every stage of their journey, whether it's the beginning, middle, or end and kind of help them work through different ways to manage that stress for the long term so that they can remain in survivorship as long as possible.

Melanie Cole, MS: Well, I can certainly attest that that crippling fear at the beginning of diagnosis is certainly something that can be debilitating and frightful. But as you go on the journey and you have that path and you have that vision of what's going to happen next, it does become clear that these are things that you can talk about and work out. So, I appreciate you saying that, Dr. Bernhardt.

Dr. Cohen, how do you collaborate with patients' Oncology team? And you can both answer this. To really ensure that holistic, whole person approach, tell us about that multidisciplinary approach and all the people that are involved.

Dr Robin L. Cohen: Well, I have to say that we are very lucky at, Northwestern here. I work in the Western region and we have an outstanding, close working relationship with the entire Oncology treatment team. And I don't want to leave anybody out. But it involves, obviously, the surgeon, surgical oncology, medical oncology, the entire incredible nursing team, frontline staff, therapists, dietician, social work. There are many, many, many, many, many specialties that all work very closely together to provide really tremendous care for all the oncology patients.

And because I've had the opportunity to work literally side by side with them, literally in an office, and we really got to know each other very well, and I think that relationship is very important. So, when I evaluate patients for their first time and there are certain issues that come up, I communicate that immediately to the oncology team, whether that be making a phone call, which I do quite regularly, or send an email and provide an opportunity for followup, and that works both ways. Of course, I didn't want to forget palliative care. So, we all have a close working relationship, and I think the key to excellent patient care is a lot of dialogue between the care providers. And I think that's really a very important aspect of this.

I've been fortunate to know that the Oncology team feels that the PMNR specialty provides many benefits for the patients, in terms of helping to maintain their quality of life and also helping them maintain fitness so they can continue on with their cancer treatment. We now, I think, recognized an essential member of the care team. And I know that Dr. Bernhardt plays an equally important role in the Oncology Care team as well. Because if you don't have good mental health, it makes it impossible really to enjoy life and participate in your care.

Dr Nicolette M. Bernhardt: And just to add on to that, everything that Dr. Cohen is saying about the medical teams that the patient's come from is completely accurate. Our patients come to us with a wide variety of team members and supportive members of their cancer journey that have been by their side from diagnosis through treatment. And so, it is often an honor and a privilege to be able to share information back to them. Obviously, my referrals, majority come through Dr. Cohen, so I always inform patients right off the bat that I will be informing Dr. Cohen about how they're doing and the concerns that I have for them, which they never have any concern about because they want her to know exactly what's going on with their care and relay that back to her.

But then, I always double check with patients to see if they would like me to reach out to their oncologist or other team members. Psychology is a little different than most specialty areas given that a lot of what we talk about is very private and personal, so they may not want to share that information. Sometimes depending on what that information is, I can I encourage them to share that little further with their doctors and members of their team if it's something that I think that might benefit their care or inform their team members of something that's significantly important.

Sometimes it's reaching out to social workers to look for financial aspects or housing pieces for patients that are struggling financially. Sometimes it's reaching out to palliative care to help with some pain management issues or even psychiatry to help with medication management for depression or anxiety. So, we work very closely with all members of the team as possible, to really help our patients get a full rounded care that they need and deserve.

Melanie Cole, MS: Thank you both for that/ and Dr. Bernhardt, can you tell us more about your four-week prehab program for stress reduction, how that benefits patients undergoing cancer rehabilitation?

Dr Nicolette M. Bernhardt: It was created in the sense of coming up with something that patients can do on their own, primarily at home, because obviously treatment and doctor's appointments takes up so much of their time. But it allows them to gain a little bit more control over their health in little ways. So once the referral has come from Dr. Cohen to myself, I'll see patients for an initial evaluation where I will assess a basic screening and cognition, substance abuse use, their cancer journey up until then, and then provide them with an overview of five different stress reduction techniques that range from diaphragmatic breathing to meditation to progressive muscle relaxation and more.

They're educated on all of those, they're practicing those in session with me, and then they're given handouts on explanations on all of the different techniques. Then they're provided with a way to track their recovery process when it comes to working through all these techniques. They're given a calendar. So on Monday through Friday, they have to practice one of the techniques. It's all laid out for them. So, maybe on Monday, it's diaphragmatic breathing. And on Tuesday, it's passive muscle relaxation. And on the weekends, they get to do something fun, but it's all planned out for whatever month that they're joining me with. And then, they keep track of how each technique works for them each week. So, they can see what helps, what doesn't, what techniques they love, what they don't. And then, after about four weeks, they come back to me. We assess kind of where they are emotionally and how they're doing. Some patients may think, "I'm doing great. This is really helpful. I love these techniques. I feel great," and they can move on and check back in as necessary. Some patients may say, "You know what? I still need some extra support and that's when they usually come and see me for outpatient visits as well. But also, during the program, I also keep track with them. I send them little weekly reminders. I send them little uplifting emails, just to kind of make sure they're staying on track, but having some control over their health journey in as much of a way as they can.

Melanie Cole, MS: I'd like to give you each a chance for a final thought here. And Dr. Bernhardt, you're a cancer survivor yourself. Please tell us how your personal experience has shaped your philosophy of care and your practice as a psychologist. How what you've gone through has really helped you to empathize with your patients on their cancer journeys?

Dr Nicolette M. Bernhardt: It's an interesting question because so many patients that I've had the privilege to see over the years, I've shared my story with. And so, they all are aware that I'm a cancer survivor, have been for almost 18 years. And the minute they find out, there is a sense of awareness of you understand where I've been and what I'm going through and where I've come from. And I think that makes a difference in the care that I provide, is that I understand the ins and outs of being both a patient as well as a provider. So, I look at things through a different lens than most people do. I think it provides my patients a sense of security and understanding, that they don't find elsewhere sometimes. Plus I do have the clinical health psychology background to provide the science and the knowledge that they're seeking as well. So, sometimes having that little extra experience, although no one wants to be a cancer survivor, it does allow me the chance to connect even closer to my patients on a deeper level that I never thought was possible.

Melanie Cole, MS: Thank you for sharing that. And Dr. Cohen, last word to you. What advice would you give fellow rehabilitation specialists who are working with cancer patients to ensure that effective and empathetic care? And wrap it all up, what you would like other providers to take away from the wonderful comprehensive program at Northwestern Medicine Marianjoy Rehabilitation Hospital?

Dr Robin L. Cohen: Having physical medicine rehabilitation embedded in the larger Oncology Program at a hospital, I think is really critical to seamlessly providing care for this patient population. It is very important to establish good lines of communication for all of the cancer provider groups. To help ensure your thoughtful recommendations and plan of care get integrated into their overall cancer treatment plan, I think that's very important.

I think it's also important to try to identify a rehab champion, so to speak, who can help introduce you to other members of the cancer treatment program. That's been very helpful for me. And constantly reassess your program and to continue to grow it, and see where there are gaps that you can help fill.

Melanie Cole, MS: Great information. Thank you both for joining us today and to refer your patient or for more information, please visit our website at breakthroughsforphysicians. nm. org rehabilitation to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please always remember to subscribe, rate, and review Better Edge on Apple podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.