Prolific child neurologist and author, Dr. Siegel uses a variety of images to explain what he thinks should be taught to children in America.
He uses his hand to provide a concrete visual model of the brain.
He also summarizes his “mindsight” model as a combination of brain, mind, and relationships. He expounds on the over emphasis of brain, or somatic, focus in mainstream culture and medical school. He argues we neglect the education of mind and relationships after children graduate kindergarten.
A Practical Introduction to Factor Analysis: Exploratory Factor Analysis
Survey questions or “items” (e.g., on a scale from 1 to 5, how strongly do you agree with the following statement…) may be repeated measures of certain underlying “factors”. Where factors are a true underlying construct that a survey attempts to measure. For example, a factor a survey may attempt to measure might be the anxiety caused by learning statistical analysis (using SPSS software). Factor analysis looks at understanding what is really being measured by multiple questions in a survey.
There are a ton of new concepts in this class, but online resources are often a more simple and clear way to learn.
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.
But it turns out, not many procedures used by physiatrists have been supported by clinical evidence.
Dr. Braddom Predicts the Future of PM&R
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
Physiatric personality: people oriented rather than rat oriented
“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
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.
“The series of reviews commissioned by SPPE over the past year shed important insights on the current state of psychiatric epidemiology [1-5]. Our reading of this series has led us into discussions of the scope and goals of our discipline, and how, within a historical context, it is expanding in both predicted and unforeseen ways. In this editorial we first reflect on the history of our field, and how the wealth of information in these reviews provides insight into newly emerging directions of inquiry. Then we discuss major advances and remaining challenges in the field not covered in the series. Finally, we consider the overall scope and future directions of psychiatric epidemiologic inquiry in the years to come.”
Academic medicine training is a long road via internal medicine.
Minimum Training Requirement in the Subspecialty Research Pathway
DISCIPLINE
IM
CLINICAL
TRAINING
SS
CLINICAL
TRAINING
RESEARCH
TRAINING
(80%)
TOTAL
TRAINING
EXAM
ADMINISTRATION
ELIGIBILITY
Adolescent Medicine
Allergy & Immunology
Critical Care Medicine
Endocrinology, Diabetes, & Metabolism
Geriatric Medicine
Hematology
Hospice & Palliative Medicine
Infectious Disease
Nephrology
Medical Oncology
Pulmonary Disease
Rheumatology
Sleep Medicine
Sports Medicine
24 months
12 months
36 months
72 months/
6 years
Fall, PGY-6
Gastroenterology
Hematology/Medical Oncology
Pulmonary/Critical Care Medicine
Rheumatology/Allergy & Immunology
24 months
18 months
36 months
78 months/
6.5 years
Fall, PGY-7
Cardiovascular Disease
24 months
24 months
36 months
84 months/
7 years
Fall, PGY-7
Tertiary certification
Add the minimum clinical requirement of the subspecialty to the Research Pathway
Transplant Hepatology
24 months
30 months
(18 GI +
12 T-HEP)
36 months
90 months/
7.5 years
Fall, PGY-8
Advance Heart Failure & Transplant Cardiology
24 months
36 months
(24 CVD +
12 AHFTC)
36 months
96 months/
8 years
Fall, PGY-8
Interventional Cardiology
24 months
36 months
(24 CVD +
12 ICARD)
36 months
96 months/
8 years
Fall, PGY-8
Adult Congenital Heart Disease
24 months
42 months
(24 CVD +
18 ACHD)
36 months
102 months/
8.5 years
Fall, PGY-9
Clinical Cardiac Electrophysiology
24 months
48 months
(24 CVD +
24 CCEP)
36 months
108 months/
9 years
Fall, PGY-9
Internal medicine training requires 20 months direct patient responsibility
Ambulatory clinics during research training (10%) ½ day per week
IM exam administration eligibility, Summer PGY-4
All other standard ABIM requirements for ABIM initial certification eligibility must be met
“The drugmaker Merck said Thursday that it would lower prices on several drugs by 10 percent or more, but its rollback affects minor products and would not lower the cost of its top-selling, expensive cancer and diabetes products.”
“Simpson’s paradox, or the Yule–Simpson effect, is a phenomenon in probability and statistics, in which a trend appears in several different groups of data but disappears or reverses when these groups are combined. It is sometimes given the descriptive title reversal paradox or amalgamation paradox.”
This seems counterintuitive, but the 5 minute video below explains the concept well.
