Physiatry in the Future

Before forecasting its future, there is likely merit in explaining what physiatry is.

What is Physiatry/PM&R?

“Physiatry, also known as pain management and rehabilitation (PM&R) is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities.”

– Wikipedia

Medicine tends to be sterile. When the end goal is reduced to keeping the patient alive, or moving a lab value within its appropriate range, doctors can forget to be human. Resources are stretched thin in a county hospital in a large metropolitan area. Providers are only attending to biological issues because they are prioritizing scarce resources. They are not trained to deal with the more pressing, social issues. What is the point in treating a patient’s asthma, discharging them back to the streets, waiting for another exacerbation, and then rounding on them next week after they’ve been admitted once again from the ER? Patients like these need social work and preventive public health measures. Instead they get expensive medications once every few months. Medical care can feel calloused and at times even cruel.

On the other end of the spectrum, there are fields based entirely in human connection, but they lack teeth. Naturopathy and alternative medicines have either been shown to have no efficacy, or there is no incentive to research them because they are assumed to be entirely based on the placebo effect. Sometimes people need to be heard and feel connected with their provider. These fields take advantage of this, and patients may be happier, albeit less healthy.

PM&R is western medicine that focuses on the patient’s function and quality of life. Chronic pain patients have sifted through the medical system, frustrated by the lack of resolution to their pain. They’ve stumped doctors who cannot do anything for them because all of their lab values are correct and they seem healthy enough by the protocol standards. Surgeons will happily perform surgery, but it seems a drastic move exposing patients to serious risks, which can be minimized or ignored during the pre-op. Surgery may be the best option for some, but certainly not all of these patients. Physiatry can offer medical treatment, alongside physical therapy for a multidisciplinary approach to increasing patient health and quality of life.

pmr_do-.jpg

But it turns out, not many procedures used by physiatrists have been supported by clinical evidence.


Dr. Braddom Predicts the Future of PM&R

Braddom

Dr. Randall Braddom is a clinical professor of physiatry. While at Rutgers Medical School in 2014, he gave a 100-Slide PowerPoint presentation that concisely summarizes the field of PM&R and it’s future direction from his perspective. Dr. Braddom acknowledges how worthless predictions of the future often are, but an experienced physician creating a deep portrayal of their specialty is worth far more than SDN forums.

According to Dr. Braddom, the field of physiatry is placing more value on research. One of the reasons is that physiatric procedures have not been validated in randomized clinical trials, and insurance companies are eliminating reimbursements for procedures without scientific evidence supporting their efficacy. The large proportion of physiatrist in clinical practice may see large reductions in their financial reimbursement for some of their procedures, such as sacroiliac and Z-joint (zygapophysial) injections.  A whole field of doctors potentially not getting paid for their work may be a powerful force. It seems that clinical research opportunities in PM&R will likely thrive in the near future.

Below are select few slides from Dr. Braddom’s presentation.


PM&R Research will Boom Soon

Trend to Evidence Based Medicine

Evidence Basis of PM&R is Significantly limited due to:

  • Variability/complexity
  • Limited research
  • Distance from molecular biology
  • Clinical studies lack analytical rigor

Research is Critical for PM&R Practice

  • Outcome Studies are key to practice survival
  • Randomized controlled trials (RCT’s)
    • Almost no other kind of research is taken seriously
    • Uncontrolled research is only a pilot study, at best
  • Laboratory moving closer to the bedside
  • New emphasis on Evidence Based Medicine in Health Care Reform

Few Physiatrists Have Become High Quality Researchers

Why?

“It has also been generally agreed that Rehabilitation research has not done well in fulfilling its objective of providing a foundation of knowledge for rehabilitation practice.”

Lieberman (1993)

AAPMR LNA: 2004 Physiatric Effort Report

  • Outpatient 50%
  • Inpatient 23%
  • Administration 10%
  • Teaching/CME 4%
  • Research 3%
  • Miscellaneous 10%

What to Do After Residency

2014 ABPMR Subspecialty Exams for Physiatrists

  • Sports Medicine
  • Neuromuscular Medicine
  • Pain Medicine
  • Hospice and Palliative Medicine
  • Pediatric Rehabilitation Medicine
  • Spinal Cord Injury Medicine
  • Brain Injury Medicine
Braddom_-_Future_2014_handout (dragged).png

What Percentage of Residents Join Orthopedic Groups?

  • 22%
  • Range from 10-40%

On residents joining Orthopedic groups:

“This is a sin against humanity!”

– PM&R Chair

From reading forums, it sounds like being a physiatrists working in an orthopedic practice may be a horrible experience. Surgeons with large personalities shunt all their conservative preventive care to one physiatrist on the team because it is a waste of their time to do injections when there are more challenging surgeries to be performed.

I personally would not want to spend so much time in training to be looked down upon or taken advantage of financially during my day to day practice. I don’t see the allure to working in orthopedic groups that the 22% of survey respondents said they are doing.


PM&R is a Great Field

  • Patients appreciate what we do
  • Not limited by an organ
  • Jobs of all types available
  • Population demographics favor us
  • Good balance of procedure/E&M
  • Many academic opportunities
  • Good physiatric profile/nice people
  • Small (10,000)

PM&R is focused on patient outcomes and quality of life. There are a wide variety of procedures, subspecialties, and practice styles within physiatry. Dr. Braddom presented many trends in the field as of 2014, and where he expects it to head in the future. He underscores the growing research opportunities in PM&R, the breadth of fellowships for sub-specialization, and that working in an orthopedic group may be less than ideal. Regardless of his prophecies, as of now physiatry looks like a promising career path.


Source

Wikipedia: Physiatry

The Atlantic: The Problem With Satisfied Patients

Doctor Voices: What is PM&R?

Doximity: Randall L. Braddom, M.D., M.S.

The California Society of Physical Medicine and Rehabilitation: The Future of PM&R From a PGY-46

NCBI: National Center for Medical Rehabilitation Research – K12 Grant

SDN: Work Under Orthopedic Surgery?

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