Keith A. Reynolds 0:00
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Speaker 1 0:26
So, I think many of my practitioners have had to, not by choice, have had to fold themselves into a situation that was different, more less autonomous is a better way to say it than it had been. I, on the other hand, have gone the other way and have become more and more independent.

Austin Littrell 0:58
Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Allison Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics senior editor Richard Payerton sat down with Dr. John Cianca, President of the American Academy of Physical Medicine and Rehabilitation, and a solo practitioner running a cash-only practice in Houston, Texas. They discuss why Dr. Sienka stepped away from insurance more than 20 years ago, and what it's meant for his overhead and a car he is able to deliver. Where physical medicine and rehabilitation fits in the primary care landscape. How the specialty was early to document the scope of long COVID, and how AI is beginning to reshape everything from clinical practice to medical education. Dr. Siyanka, thank you for joining us. And with that, let's get into the episode.

Richard Payerchin 1:51
Thank you for joining us today.

Speaker 1 1:53
You're welcome.

Richard Payerchin 1:55
And we're gonna get into some issues involving the association and your practice. Just to get us briefly started, briefly here, can you introduce yourself and the association?

Speaker 1 2:05
Yes, as you said, I'm my name is John Cianca. I am a private practitioner in Houston, Texas. I have an adjunct affiliation with the Baylor College of Medicine and the UT School of Medical or Medical Sciences in Houston, so I do some teaching, both locally and nationally. My practice is a little bit unique in that it's an outpatient musculoskeletal practice, which is not unique, but the fact that I do a cash practice is so it's a smallish practice, but very patient focused.

Richard Payerchin 2:43
Just wanted to start off with a big picture question regarding the specialty. What's the biggest challenge facing the specialty right now?

Speaker 1 2:51
Well, physical medicine is a broad specialty. We take care of kids to senior adults, and we do so in across the spectrum of medicine, in so far as we take care of people that have acute injuries that are catastrophic in nature to more longstanding issues that are day to day, so my end of the field is less in the catastrophic realm and more in the day to day musculoskeletal injuries that slow people down, but don't necessarily leave them disabled, at least not permanently. My colleagues, on the other hand, take care of people that are impaired permanently, usually brain injury, amputees, effects of stroke. So internally, one of our challenges is appealing to everybody in the field in a way that's common to everyone, so reaching everybody across their varied practices can be a little bit of a challenge internally, insofar as being able to be on message for everyone externally, it's a longstanding issue that rehab is sometimes an afterthought, you know. There's acute care medicine, everybody thinks in terms of, okay, what are we going to do right now? How are we going to treat these people? Can we keep them alive? But what are you going to do after that? And that's where we come in, and so sometimes that's overlooked or not appreciated till you know it's the wheels are already should be in motion, so I would say recognition of what we do, how we fit into the picture of medicine as a whole, and getting us involved early enough that we can make a difference sooner and more efficiently, basically getting people back to their lives,

Richard Payerchin 4:43
you know. What, Doctor, I think that's a great segue to a question that, you know, anytime we talk to a specialist, we always like to look for those intersections, particularly with primary care. To maybe elaborate on that a little bit more, talk about some of those communications and perception issues. What misconceptions. Do you encounter about physical medicine and rehabilitation among primary care physicians, and what would you like PCPs to better understand about the scope and value of your specialty?

Speaker 1 5:13
Well, I would say many of the misconceptions have cleared during my career. I mean, early on we were looked at as inpatient doctors, and then my generation of physicians started doing outpatient, and that early on was construed as chronic pain only, or back pain only. So, over the course of my career, now we've been recognized more and more as experts in musculoskeletal care, from acute to chronic post-surgical to non-surgical, so I think a lot of those misconceptions have waned, but not everybody thinks of physiatry, physical medicine first. They often still kind of default to orthopedics, and orthopedics certainly welcomes those kinds of cases, but if they're non-operative, why would you send to an orthopedist? Because they're not going to be as interested in the long-term care of such an issue as we would, so physiatry is really a specialty that deals helps people across a spectrum of time, not just for an incident, and, and letting people know that specialists or patients themselves is still a bit of a challenge, you know, our our ability to maintain a relationship with somebody beyond just an incident is still probably not top of mind for a lot of people,

Richard Payerchin 6:45
you know, Doctor, in not to belabor the point, but to go back to something you might have mentioned, I think you did mention a moment ago regarding that perception as an inpatient physician, and then that change over time, I guess. When you mentioned about inpatient, would that be like a physician who might respond to a person with an acute injury and trying to help them regain certain health while they're still perhaps hospitalized? I guess could you explain maybe that a little bit?

Speaker 1 7:15
Yes. Well, so historically our field has dealt primarily, what dealt a lot with people that come to hospital with a major problem, they lost a limb in the war, they've had a head injury for whatever reason, they've had a stroke, they, you know, have had any sort of illness, injury that puts them in the hospital and requires an extended stay, which almost by necessity would include some rehabilitation, so they could exit the hospital, and of course that's where we came in, and we did. We still do that, and that was our entree into the house of medicine, per se, and it really a lot arose because people started surviving these things we invented, or we discovered antibiotics, which kept people alive. They didn't die from infections, now they lived, but they had no limb, or they had an impaired the left side, or they had a brain that wasn't as sharp as it used to be. So, what are you going to do now? You know that's where we came in. We help these people accommodate to their new situation, maybe overcome it, and certainly adapt to it, and in that setting we were working in the hospitals. The sooner that we got involved is always better, and that happens variably, depending on the environment you're in, but it's the best way for us to be involved, but certainly as their stay progresses, we become involved, and then we stay involved after their discharge. So that's the hospital-based end of our field, and how it arose, and how it's changing. I think more and more people realize that sooner is better with respect to beginning at least the footings of rehabilitation, even if it's not full on early on in the course.

Richard Payerchin 9:10
I'll tell you what, I'll switch gears a little bit, because this is something that I think that we're all glad that the COVID 19 pandemic is is behind us, but the Academy was really a leading medical organization that began documenting numbers of patients dealing with long COVID and their health conditions. Why was long COVID so important to the Academy?

Speaker 1 9:33
Well, we recognized early that it was going to be an ongoing problem. People did survive, unfortunately, many did not, but those that did survive had a, and do have a host of problems that became obvious to us that we're going to need attention, and we've had history with this kind of situation. Polio, for instance, polio affected people broadly in a number of ways, we. Were front and center to helping those people deal with the after effects, so we recognized there's probably going to be a need here as well. So we got involved in the post Covid infection environment very early, and I think we made a big difference in helping to the public in general, and maybe even the government, recognize that this isn't just a one-off virus. It either kills you or you survive. Many people still are dealing with effects of COVID in some form. I've seen people recently that said, you know, I had COVID three years ago, and I've never been quite the same, either, for something like their endurance or their ability to tolerate things that they normally did or previously did without any thought, and now they have to prepare, or they have to recover. So, you know, to our credit, I think we saw what was going to happen, and we got to it, and I think many of our many of my colleagues were very adept at recognizing it, and then coalescing people to help present this to the world as a thing, something that we're going to have to deal with.

Richard Payerchin 11:15
And to follow up on that, How would you describe the current state of care, so to speak, for patients, for those patients who are dealing with long COVID in the US healthcare system.

Speaker 1 11:25
Well, I'd have to say this is more of an estimate, because I am not really on the front line there. But what I've gathered is it's actually probably somewhat harder, because people have forgotten about it, you know. And I say that meaning the people that didn't have COVID, the people that are, you know responsible for supporting health care in that setting, you know, we're having to remind people, look, this is a this is something that happened. Yes, it killed millions of people, but it also affected millions and millions more, and there's fallout from that. We have to remember, we have to keep the edge, so to speak, on care and recognition of these potential problems, and what, what it amounts to, and it, in particular, with respect to the people that we had already treated, the disabled, in large part, it affected them even more, or could have affected them even more, so it's an ongoing issue, and I would say not necessarily easier than it was in terms of the peripherals to getting care and accessing care,

Richard Payerchin 12:34
you know, Doctor, and if I may, I'll switch gears again a little bit, because the traditional audience of medical economics, we've, you know, over time, have served a lot of internal medicine and family medicine physicians, especially those remaining in smaller and medium-sized independent practice. Our magazine, at times, appeals to other specialists who are also independent operators, so to speak, and are looking for kind of news about, for example, policy or management tips, things like that, based on your own experience as an independent practitioner, what do you think are the biggest challenges right now to big picture in our country in the healthcare system? What are the biggest challenges right now to maintaining independent practice?

Speaker 1 13:15
That it's actually a giant challenge for many of my colleagues, insofar as survival, you know, being financially viable, of being able to keep pace with the demands of a healthcare system that is, let's say, challenging, meaning the administration thereof, and the payment of it, many, many small practices have been bought in some way or another, either by large institutions or by private equity, or by other groups, so that in some respects there's power. Well, there definitely is power in numbers, and that could be at the level of still an independent practice that's just bigger, but it also could be at the hands of somebody else who's overseeing that practice and saying that in a kind way, because it really has changed the way that kind of care, outpatient care, is being delivered. It has become very bottom line focused, very much an efficiency model, and that's challenged the care part of it, if you will. So, I think many of my practitioners have had to, not by choice, have had to fold themselves into a situation that was different, more less autonomous is a better way to say it than it had been. I, on the other hand, have gone the other way and have become more and more independent. I was probably fortunate that I started that before there was a critical need to make a change, so many of my colleagues. Things have gotten caught up, caught up in this sort of churn of outpatient practices becoming big institutionalized practices

Richard Payerchin 15:11
with a, with a physician-facing magazine, with the physician audience. We try to write from that perspective, but I always tell people, full disclosure, I'm not a, I'm not a physician myself. I have been a patient, I'm a person who pays for health insurance, and so we have some perspectives, both about physicians dealing with health insurance, and perhaps some expectations. Prior authorizations is a big thing in our space, and then we have some patient perspective too, and I guess where I'm going with this is just to ask if you could maybe talk a little bit more about your own experience and what influenced you to work in a cash only practice.

Speaker 1 15:50
Well, it is an interesting question, because I, as I said earlier, it started doing it 22 years ago when it was still there, was people doing it, but it wasn't so unusual in the sense of what we have now, which is these vast systems. I did it primarily to allow myself to see people the way I thought was best for me and for them. I recognized early that I don't like or excel in treating fast and in volume. I much prefer to see people at a pace that allows me to spend time with them, speak to them, teach them, and affect them, not just do something to them, but to change their course, that requires time. I don't know how else to do it, and therefore I sort of chafed at was what was being presented to me, which was, well, you got to see more patients to make your salary, and I was so ardent about what I wanted to do, I even suggested, well, why don't you just change my salary, so we don't have that pressure, and that got resistance, believe it or not, and I kind of understand that there's sort of a, an, a given template for how a hospital or a medical college needs to pay their pay or pay their employees, and that just didn't fit. So at that point I left the medical college that was associated with Baylor amicably, and started alongside of them, meaning as an adjunct, doing my own thing without insurance, without private insurance. I still took Medicare for many years after that, and that allowed me then to reduce volume and not reduce income. Now, I didn't - what I'll be careful to say - is I didn't get involved in that to make more money. In fact, I make less money than most of my colleagues who are treating volume and trying to keep up with the pace that they, or the financial pace that they had before. I didn't, that wasn't central for me. It was about providing care, and the monetary means, or monetary rewards, were second secondary. So, over the years, I've gotten more efficient, and things work better, but it was a struggle early on, despite feeling better about the care I was delivering financially. It was, it was difficult. That's an, that's a hurdle you have to deal with if you're going to go the way I've gone. You can't just expect that your office is going to be full. I had 11 years in this area, so people did know me, and it was still hard, so it's a challenging way to go. I was fortunate to get in early, before people really were feeling the pressure of new styles of practice, which is higher volumes, less time with people, more administrative demands, and difficulties

Richard Payerchin 19:03
again. I find it fascinating only to consider different business models that work in different markets for different physicians, but then also, like I said, the notion of not having to deal with private insurance. I'm guessing that you're.. I don't want to say.. I don't want to assume that your courses of treatment go smoother because you don't have insurance working as a middleman, but I guess, could you describe what that's like to not have

Speaker 1 19:30
that burden? Yes, I can. Well, first, a factual statement: my overheads way lower. Right, I work alone, I have a true solo practice. There's no front desk people, there's no MA's, there's no PAs. It's just me. I greet them at the door, I treat them, I check them out, I reschedule them, I answer the phone. I don't have to deal with paying people, I don't have to deal with chasing down approvals ahead of time, I don't have to deal with chasing money later. Here, so I'm much more efficient, but you know the issue of what to do, you know, when you're in a cash practice or in a paying practice, you have to deal with all those things, which makes practice more complex. So I have rid myself of that, and it allows me to function at a more efficient level.

Richard Payerchin 20:24
Looking at different business models, there are certain efficiencies that you gain when you grow, and I think you touched on that, but then there also become certain obligations. That's within the context of the healthcare system, but then also, like I said, the notion, the health insurance acting as a mediator or a go-between between a physician and patient. Sometimes I just like I said, it's a dynamic that our doctors deal with a lot, and I think find very, very frustrating. And so to not have that perspective, I think I think people are going to find that fascinating.

Speaker 1 20:57
Well, thank you for reminding me, because the other part to your question, was does it make things easier or harder for not having to deal with insurance? It makes it much easier because I don't have to justify what I believe is clinically correct and reasonable. I don't have to deal with people who don't understand what they're proving or not approving, and that is very common, that you know my colleagues have to talk to people that are going to say yay or nay, they don't really understand necessarily what they're they're overseeing, and that's frustrating for my colleagues. I don't have that issue, so I can deliver care in a timely fashion for somebody without all the delay or denial, which is of course even worse, because then you can't even deliver the care. So, in my view, I think my product is better, and I say that because people get what they need without all the obstacles put in their way, and the delay that that is entrenched with it, and it, there's a lot, there's less compromise, there's less having to work around an issue. So I think ultimately I can get to the root of the problem in an efficient manner. Let's take a for instance, somebody comes in with arthritic knee, and in order to really treat them well, we might want to do something more advanced, but we have to do step one, two, and three first before the insurance will even think about recognizing the other more efficient, more long-lasting treatment, and for I'm not sure what the rationale is. I guess saving money, but ultimately you had to do those first three steps, which all cost money, you know. I'm not sure that's that's a savings, it's just a delay. So, you know, that's my take on it. That may not be entirely accurate, but I think it's pretty close.

Keith A. Reynolds 23:10
Hey there, Keith Reynolds here. And welcome to the p2 management minute. In just 60 seconds, we deliver proven real-world tactics you can plug into your practice today, whether that means speeding up check-in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom, they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at K reynolds@mjlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute. One

Richard Payerchin 24:01
thing I was kind of curious about is regarding healthcare technology. Can you discuss how PM and R physicians may be integrating remote therapeutic monitoring into their practices?

Speaker 1 24:17
I'm not, but I know some of my colleagues are, particularly people that have, you know, ongoing issues that need to be monitored, if you will, you know, to some extent, we do that therapeutically with the treatment of spasticity and or chronic pain by the use of central devices, pain pumps, spasticity pumps, and what we're doing is adjusting over time using this technology to cater to their individual needs at any one point in time, either by either through pain management or spasticity management. There's other types of remote monitoring, obviously, that can help with fit. And or monitoring physiology during fitness, those are all good things, and I think we have long been recognized, recognize we long recognize that technology can be a real help to our population, just you know, think of the complexities of a disabled person, you know, and what we've done now with prosthetic limbs and power wheelchairs and ways of communicating with brain-injured folks through the use of technology that was not available before, so we're very practically oriented specialty, and I think the use of technology has really helped us stay practical and deliver treatments or adjuncts to treatment that make the care relevant and timely, as well as up to date. So, I think technology has been a boon for our field, and I think we've been very good at adopting it and, and moving forward, and actually innovating it. I have younger colleagues who are doing things that I never could have imagined we were doing, and this is in the outpatient setting, treating problems through non, or I would say, micro surgical techniques that aren't really surgery and are done in an outpatient setting, and the patient goes home the same day.

Richard Payerchin 26:25
You know, it's a great segue to another question that comes up in just about every interview now, because one thing that's been curious, or that we've been curious about, and I think we're seeing both in our own work as well as the doctors that we talk to, artificial intelligence, you know, has moved to become an issue in across many different sectors of business. Can you talk a little bit about how physiatrists are using AI in their practices? Where is the specialty kind of merging with AI?

Speaker 1 26:54
It's AI in and of itself is going to be a huge influence, probably positive and possibly negative, and I think that's true across society, right? I mean, it could literally change the way we live, and that yet we don't know how yet, you know. So we've seen it very rapidly change things, and I think we're just scratching the surface, but with respect to what we do, and this is really a concern of my society, the American Academy of Physical Medicine and Rehabilitation, for instance. How do we deliver education? Well, historically, we did it through in-person learning, and then we evolved to more online learning and micro learning through various forms of technology that allow immediate access with AI that may all go away, so we're having to adjust. How are we going to deliver education? Do we even need to deliver education? Because it's so readily available by just tapping into AI, and in fact that is happening at the resident level. It's just so easy for them, rather than to go and read an article, to just tap into AI and find out what the, with the consensus of literature is not just one article, but multiple articles condensed and summarized, so it, you know, ultimately could be a good thing, but it's going to affect us as a society, meaning my professional society, and I think that's true across all medical societies. They're trying to figure out how we're going to use this without getting made obsolete from it, but you know, on the other hand, as I mentioned earlier, it could be very good for making healthcare efficient, because you've got all that information now right at your fingertips, without having to take the time to consolidate and track it down, and or if you don't even have access to it by way of presence, you have it virtually, so remains to be seen, it's going to be a big influence, and you know how we adapt or adopt it, maybe it's better, is going to influence whether it is a positive or negative, and that you know that's all I can say at this point, because I think I don't know much about it, but I've seen big changes in my lifetime, and this represents to me probably even the biggest change that may happen.

Richard Payerchin 29:24
No, I think I think we're still, you know, at the tip of the iceberg on that one. And this is a question, this is a kind of a segue into another question that comes up in just about every interview as well, because you know in our country right now under the current administration there is an initiative to make America healthy again. How do you think physical medicine and rehabilitation as a specialty contributes to that national initiative?

Speaker 1 29:53
It's not news to us, that's the way we've been going all along, you know, and it's sort of by necessity, right? When you're dealing with somebody's function, you know, not their broken bone or not their brain bleed, but the results of that, you have to very quickly understand their environment and how to make things work, both from their internal locus as well as the external locus, you know, we have long done work outside of the hospital with people, sending them home on a weekend to get into their adaptive apartment, so that they can then be ready to go to their own apartment or home in a more safe and functional way, so you know, I think making America, or making America healthy again. We've, we've been doing that. I mean, we've all long recognized the need for movement and exercise as being central to care, central to health. I mean, the addition of diet probably is something that may be relatively new to my field, but it's not really. I mean, I think we've always had that outward-facing view on how to help people adapt and be able to thrive. It's just something that was part of the way we thought, and the part of the way we delivered care. It wasn't isolated, it wasn't so narrow and focused, rather it's more about their big picture, and that's, you know, to me that that's why I think we've always been effective. One of my colleagues said to me about the area of lifestyle medicine, which is a burgeoning field. She was encouraging me to get involved, and then she said, "Well, but you've already been doing this anyway, which is true. You know, it's just something that we do, sort of by way of our training, but also the problems that we have to treat, you know, it demands that outward focus,

Richard Payerchin 32:04
you know. Doctor, we've covered a heck of a lot of ground, and we're coming down to about the two minute warning here. One question I always like to add, we can talk a lot about a lot more things. I'm not trying to cut you short by any means, but one question I always like to ask, of course, our main audience is primary care physicians. What would you like to say to them, or what would you like them to know?

Speaker 1 32:23
You know, we're happy to partner with them. I mean, with something that we look at as the entrance to our practices, you know, primary care for many, many, many years has been the gateway, and we have really tried to educate primary care practitioners as to what our capabilities are. I think some of those were obvious when you're dealing with people in the hospital who need rehabilitation. Okay, let's get a physiatrist involved. However, in the areas that I'm in, which is a little bit more subtle and historically been the sort of focus of orthopedics that's been a slower revelation and I, for me, it's important that we continue to communicate our capabilities and our expertise to such specialties, primary care, whether it's family practice or internal medicine or pediatrics that we can do this, and in fact it's probably we're better suited to it than most, because of the breadth of how we look at a problem, rather than a simple focus on I can fix this or I can't. We do more than fix, we help people adapt, so that's really where I think the ongoing message to primary care needs to be. It's like, you know, what do you need and who can best provide that? And I think that is what we can do.

Richard Payerchin 33:52
I'm Richard Payerton, reporting for Medical Economics. My guest today has been Dr. John Cianca, the President of the American Academy of physical medicine and rehabilitation, Doctor. It's been a great conversation. I hope we get to talk again soon.

Speaker 1 34:05
Thanks, Rick. It's been a pleasure

Austin Littrell 34:16
once again. That was Dr. John Cianca, President of the American Academy of Physical Medicine Rehabilitation, speaking with Medical Economics senior editor Richard Payerton on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask you, please subscribe, so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories, and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts, and if you'd like the best stories that Medical Economics and Physicians Practice published, delivered straight to your email six days of the week, subscribe to our newsletters at Medical economics.com and Physicians practice.com Off the Chart, a Business of Medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds and produced. Is by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai