Meet the Experts: Eric Wisotzky

Meet the Experts: Eric Wisotzky

Gary: For our next feature, we are highlighting Eric Wisotzky, a rising star in the world of PM&R.  Eric is a national leader in the emerging field of Cancer Rehabilitation, and has an interesting background that includes time in the military, and leadership work in education.

Eric and I met one another through the world of resident education.  For several years, I ran the Resident and Fellow Workshop at the annual meeting for the Association of Academic Physiatrists.  My co-coordinator Chris Visco was Eric's residency mentor, and Chris praised Eric so highly that Eric became the first resident to serve as a teacher at the workshop.  Several years later, when Chris and I were planning our succession, Eric was a clear choice to take over the workshop, which he now leads along with James Wyss.

Let's start there by way of introduction.  Eric, can you tell us about your love of resident and fellow education?

Eric: I personally felt that many of my educational experiences, especially as a medical student, left a lot to be desired.  As a medical student, I clearly recall times when I said to myself, “It will be my mission to ensure that future students have a better educational experience than mine.”  In that regard, I try to make the educational experiences of my medical students and residents as academic and as fun as possible.  I personally believe that the academic factor and fun factor are equally important and will lead to the most effective learning environment.

Gary: Interesting.  I think that rings true- much of my motivation to become a teacher was, like yours, rooted in less than satisfying experiences as a student.  Similarly, I find that many of my motivations as a physician are rooted in less than satisfying experiences as a patient. 

How do you feel your love of resident and fellow education carries over into your interactions with patients?

Eric:  I feel that the teaching environment that I work in greatly enhances my patient care.  My patients generally enjoy interacting with my residents.  I’m surprised at the number of times patients disappointedly ask me on follow-up visits, “Where is your resident?” if I do not have one with me that day.  I learn a ton from my residents.  They learn from other doctors that may use different approaches and my residents will often say, “Dr so-and-so likes to do this in this situation.”  I consider myself fairly open minded.  I don’t mind when the resident brings up other suggestions and I often learn new approaches this way.  I strongly believe that as supervising physicians, we need to remember that we are not necessarily smarter than our med students and residents, we are simply more experienced.  I feel that not utilizing the brainpower that a student or resident brings to the table is a lost opportunity for patient care.

Gary: Seguing into communication, one of my favorite things about you is how good it feels to talk to you.  I've noticed a few strengths in your communication style- you project warmth, but you also clearly reflect with detail that makes it apparent that you've heard the content of my message.  Two questions for you.  First, is that consistent with how you view yourself as a communicator, and second, is that something that comes natural to you, or is that something you've cultivated over time?

Eric: Yes, I do view myself as a good communicator.  It is something I pride myself upon.  I get such great pleasure out of seeing the understanding on a patient’s face when I explain their medical condition to them.  It is really gratifying when a patient says, “Oh, I never understood what was going on with my body until now.”   I never really understood why some doctors have such a difficult time not speaking medical jargon to patients.  The way I always think of it is that non-medical speak was my first language.  I learned “medical language” later in life.  Therefore, I still think it’s a lot easier for me to explain a patient’s medical condition in laymen’s terms, because the laymen’s terms are my “first language”.

I would like to think that I am very attuned to my strengths and weaknesses.  I am very self critical so I feel very aware of what I need to improve upon.  I know communication is a strength of mine.  I cannot say that I have cultivated it, for whatever reason it has come naturally to me.

Gary: Can you talk more about your military background, and how that has shaped the way you view medicine and communication?

Eric:  I was in the United States Navy for 5 years, 3 of which I served as a flight surgeon.  This essentially means that I was the primary care physician for a group of military aviators.  I took care of a C-130 squadron and had the opportunity to travel the world with them.  My military experience was the most important contributor to my professional development.  Before I worked in the military, my professionalism needed a lot of work.  I learned great leadership skills in the Navy.  My experience in the military makes it harder for me to deal with the managed care system now, because in the military you generally can do whatever you feel is the right treatment for that patient. 

  

Gary: Another thing I've admired about you is your willingness to invest yourself in a career that most people do not know much about.  Can you explain what cancer rehabilitation is?

Eric: Cancer and cancer treatments can really wipe people out.  A huge percentage of cancer patients are healthy and feel good when they are diagnosed with cancer.  It’s not until after they are treated that they become fatigued, deconditioned, and have pain and balance problems, amongst other issues.  Rehabilitation is a standard part of treatment for people who have strokes or brain injuries.  However, historically we have not rehabilitated cancer patients despite major changes in their functional status after cancer treatment.  Cancer rehabilitation aims to bring patients back to their baseline function after battling cancer.

Gary: I am sure a common question you hear is "why do I need a cancer PM&R physician, when I already have an oncologist?"  Shed some light.

Eric: In my mind, this question is like asking, “why do I need a hairdresser when I already have a plumber?”  The skill sets and training of an oncologist and a PM&R physician are very different.  Oncologists are fantastic at treating cancer.  We know this because patients with cancer are living longer and longer.  In the system I work in, the oncologists love working with me, because I help the oncologists do what they do best – treat cancer.  Rather than the oncologists having to spend tons of time trying to manage all the functional side effects of treatment, they can put those issues in my hands.  While most oncologists get some training and experience in managing functional side effects, in general they are not very good at it.  I’m not putting them down in any way, it is just not what they are trained to do.  The oncologists I work closely with agree with this point.  That’s why they love sending patients to me.  They can spend more time with the patient talking about cancer.  I can spend lots of time with the patient talking about their function.  The patients go back to the oncologist and thank them for referring them to me.  Everyone is happy.

Gary:  That's such an important message.  Can you talk a bit more about the role of exercise for patients with cancer? 

Eric: Exercise is a booming area in cancer care.  The body of evidence that demonstrates that exercise can decrease the risk of cancer recurrence is overwhelming at this point.  Studies have shown that exercise can reduce the risk of cancer recurrence just as well as hormone medications such as tamoxifen.  Many experts believe that in the future, all cancer treatment protocols will include exercise, such as: “surgery, chemotherapy, radiation, exercise”.  At this point, any oncologist who is not recommending exercise for their cancer patient, unless there is an obvious contraindication, is doing their patient a major disservice.

  

Gary: In particular, can you talk more about risk of fractures in cancer patients?  I find that many oncologists are so concerned about patients falling and breaking a bone, that they discourage their patients from exercise out of a sense of fear.

Eric: Most cancer patients are not at high risk for fracture.  If cancer has spread to bone, there is a potential risk for fracture.  Scales exist that can help predict the risk for fracture.  If the risk truly is high, often surgery will be recommended to fix the bone before it fractures.  This is because it is safer and easier to fix a bone before it fractures than after it fractures.  For patients with cancer in their bones who are not at high risk for fracture, exercise should be encouraged.  Pain is a great guide.  If a certain exercise causes pain in the area of bony cancer, that exercise should be avoided.  If it does not cause pain, the patient can keep going!  One important additional factor to consider is the patient’s balance.  Chemotherapy can affect nerves, which can impact balance.  If a patient’s balance is considerably affected, then they may be at higher risk of falls and fractures.  This is something that a PM&R specialist can assess and help manage.

Gary: Even amongst the small world of cancer PM&R specialists, you are even more specialized in your usage of ultrasound as a tool to help patients.  Can you tell us more about how ultrasound helps you with your patients? 

Eric: In general, my use of ultrasound is no different than any other musculoskeletalmedicine physician.  It is common for me to see breast cancer patients with rotator cuff tendon problems.  Ultrasound is so useful to characterize these problems in the office.  It is certainly useful to help in performing accurate injections. 

More specifically to the cancer population, I have started performing some less commonly performed nerve injections using ultrasound.  For example, it is very common for breast cancer patients to have pain in the armpit area after lymph nodes are removed.  I never really understood why until I learned my surgical anatomy.  There is a nerve in that area called the intercostobrachial nerve that causes this pain.  I studied the anesthesia literature which helped me learn how to perform an ultrasound-guided injection to block pain from this nerve.  This technique has been very helpful for my patients. 

Another example is in head and neck cancer patients (who badly need rehabilitation).  There is a nerve in the neck that can be affected by surgery and radiation called the greater auricular nerve.  If injured, it can cause severe ear pain.  When I first started seeing these patients with ear pain, I did not know how to explain it.  However, after studying my anatomy, I realized this nerve was the culprit.  I learned how ultrasound can help me inject around this nerve to decrease pain.  So, while I clearly do not need ultrasound to help all of my patients, it can be a very helpful tool for certain patients.

Gary: The more I talk to you, it makes me wish we were in the same region.  So many patients would benefit from your care!  For physicians like my partner Garrett and I, what we can we do to help our patients who have cancer?  In particular, I have some patients who I have already been seeing for other conditions, who then develop cancer.  How can I best be their advocate?

Eric: It is important to think about the pre-existing musculoskeletal, neuromuscular, and functional issues that your patient already has and how they may be affected by cancer.  If your patient has shoulder issues, they most likely will worsen after a breast cancer diagnosis without rehabilitation.  If your patient has a nerve issue, this most likely will worsen if your patient is treated with chemotherapy.  If your patient has difficulty walking, this can worsen after cancer treatments.  The good cancer rehab doctor will try to preempt functional loss that can occur during the trials and tribulations of cancer treatment.

The basic principles of what a cancer PM&R physician does are minimally different from what most PM&R physicians do.  In general, most physiatrists can take great care of these patients.  However, I do believe there are some subtleties to caring for cancer patients.  The first thing that really helps is having a decent understanding of cancer treatments.  You don’t have to be an oncologist, but having a basic understanding of the treatments helps me understand what has happened to my patient’s bodies and how their function has been affected.  Secondly, I think there are few little tricks I know that seem to work well for cancer patients.  I believe going to a cancer rehabilitation symposium like Sloan-Kettering’s annual symposium is a great way to learn some of these tricks.  Also, we should be pushing our national leaders to include cancer rehabilitation lectures at our national meetings.

Gary: Eric, thanks again for this interview.  I sincerely feel that you are one of those people who always brings something positive to the table, and never leaves anything negative.  Thanks for making the world a better place