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?

The Expanding Scope of Psychiatric Epidemiology in the 21st Century

“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.”


Source

NCBI: The expanding scope of psychiatric epidemiology in the 21st century

American Board of Internal Medicine: Research Pathway

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

Source

American Board of Internal Medicine: Research Pathway Policies and Requirements

Sushi Rice

Large amount of seasoned rice that can be refrigerated and used in weekly meals


Ingredients

  • 1/2 cup rice vinegar
  • 1/2 cup soy sauce or 1/2 cup miso paste
  • 3 cups dry brown rice (rinse first)
  • 5 cups of water

Prepare

Wash rice repeatedly until water remains clear

Strain rice in mesh sieve

Mix all ingredients in medium-large pot

Top pot with lid

SushiRice_Prep_660x495.jpg


Cook

Turn stove to max heat until boiling

Once boiling begins, reduce heat as low as possible while bubbles still forming

Let boil with lid on for 70 minutes

Keep lid on for at least 20 more minutes

Serve or let cool overnight and place in fridge in the morning

SushiRice_Cooked_660x495.jpg


What to Do with All that Sushi Rice?

Well you can, you know, make sushi with it

I keep the rice in my fridge and eat it with whatever I have at the moment.

It’s a good base for a chicken and broccoli bowl, or whatever meal you can imagine.

I like adding it to salads; for example, mix:

  • Spinach
  • Bit of red onion, chopped
  • Jalapeño, chopped
  • 1/4 cup of raisins
  • Fresh basil, minced
  • Fresh mint, minced
  • Dash of garlic salt
  • Dress with 1 tbsp of toasted sesame oil

SushiRice_Salad_660x495.jpg


 

Simpson’s Paradox

From Wikipedia

“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.


Source

Wikipedia: Simpson’s paradox

Minute Physics: Simpson’s Paradox

Pecan Cinnamon Roles

My grandma learned how to make these during HomeEc in the 60’s, so you know they’re good.


Traditional Roll Dough

This dough recipe is enough for two pans worth of cinnamon rolls.

Ingredients

  • ¼ cup warm water (105º to 115º F)
  • 2 ¼ teaspoon (1 pack) active dry baker’s yeast
  • ¼ cup sugar
  • ¾ cup lukewarm milk (scalded then cooled)
  • 1 teaspoon salt
  • 1 egg
  • ¼ cup shortening, butter, or margarine, softened
  • 3 ¾ to 4 cups all purpose flour (if using self rising flour, omit salt)

Activate Yeast

Dissolve yeast in warm water; wait 5-10 minutes.

Sprinkle the sugar in warm water yeast mixture.

If bubbles appear, the yeast is good.

Mix it

Stir in milk, salt, egg, shortening and 2 cups of the flour.

Beat until smooth

Work the Dough

Mix in enough of the remaining flour to make dough easy to handle.

Turn dough onto lightly floured board

Knead until smooth and elastic, about 5 minutes.

Let it Rise

Place in greased bowl and cover it with a towel.

Allow the dough to rise in a warm place until it doubles in size, about 1 ½ to 2 hours.

The dough is ready if impressions remain.

Divide the dough in half.


Pecan Cinnamon Roll Topping

Prep the pans with this pecan topping while waiting for the dough to rise.

(The pecan topping can be skipped to make plain cinnamon roles.)

Note, these ingredients are for a single pan.

Ingredients

  • ½ cup pecan halves
  • ¼ cup (2 oz) unsalted butter
  • 3 tablespoons light corn syrup
  • ½ cup of brown sugar (packed)

Spread and Drizzle

Spread pecans over bottom of baking pan.

Melt butter or margarine; stir in brown sugar and light corn syrup.

Pour mixture over pecans.

Repeat the above for pan number two.


Plain Roles (No Topping)

Spray the pan down with Pam or another cooking spray and you’re good to go.

CinnamonRoles_NoTopping


Cinnamon Rolls

This step is sufficient for one pan of cinnamon rolls.

Rinse, wash, repeat for the second batch.

Ingredients

  • ½ recipe Traditional Roll Dough (see above)
  • 2 tablespoons unsalted butter or margarine, softened
  • ¼ cup sugar
  • 2 teaspoons cinnamon sugar (1 part cinnamon to 12 parts white sugar)

Roll it Out

Sprinkle flour onto a cutting board to prevent sticking.

Roll dough into a 9×22 inch rectangle.

Spread warm butter, and sprinkle with cinnamon sugar.

Roll up the rectangle, beginning with the wide side.

Pinch edge of dough into roll to seal well.

Roll the sealed roll over the board to pick up excess sugar.

Stretch roll to make even.

Slice it Up

Cut roll into 12 slices (~1 inch in length)

Grease the pan if not using the pecan topping

Place slices slightly apart in pan or in greased muffin cups

Let rise until double in size

To help the rolls rise in the pan, place in oven set the oven to 100ºF.


The Second Rise

Let the rolls rise 20 minutes before baking.

CinnamonRoles_SecondRise


Bake 375ºF for 30 minutes

Heat oven to 375ºF

Bake 25 to 30 minutes or until browning

CinnamonRoles_Baking


Flip it

If making pecan rolls, flip pans over immediately after removing from the oven

This lets the syrup drizzle down.

CinnamonRoles_Final

Excerpts: The Profits of Nonprofit

The Profits of Nonprofit

The surprising results when drug development and altruism collide

By Megan Scudellari | January 1, 2011

“In 2002, the company identified a promising off-patent antibiotic once cast aside by a large pharmaceutical company for its lack of profitability. Since the drug had been previously approved and marketed in the late 1950s as a broad-spectrum antibiotic, iOWH was able to skip directly to a phase III clinical trial to test the drug as a treatment for visceral leishmaniasis. The trial commenced in 2003, and just three years later—record time in the drug development world—paromomycin was approved for sale in India…”

“Though the idea of a nonprofit pharmaceutical company is still new, nonprofit foundations and institutes have long been a staple in biomedical research funding in the United States. But they too are breaching the barriers between profit and nonprofit, adopting best practices from the for-profit business world…”

“Victoria Hale has also made a move toward borrowing business strategies, this time not only to enable nonprofits to develop drugs, but to make and market them without Big Pharma’s help. In 2008, she left iOWH to found a “second-generation” nonprofit pharmaceutical company called Medicines360. With a focus on women and children’s health, Medicines360 aims to become self-sustaining over time, using revenue from sales of its products at a premium price in the West to subsidize the same products for those who can’t afford them in developing countries. The company is currently developing an intrauterine device (IUD) for contraception…”

“In the United States, L3Cs, low-profit, limited-liability companies, now bridge that gap. Eight states have passed legislation that permits the creation of L3Cs—defined as socially beneficial for-profit ventures. Many companies have adopted the status, including alternative-energy companies, newspapers, and food companies, but no pharmaceutical or biotech company has yet attempted the model, according to L3C experts. That’s not to say they won’t, however.”


Source

The Scientist: The Profits of Nonprofit

Powered by WordPress.com.

Up ↑