Musculoskeletal Fellowship Training: Where Are We Going in PM&R?

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Disciple

Disciple

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Anybody happen to read Dr. Cifu’s latest “From the President” column in the Physiatrist (AAPMR newsletter)?

We discuss this issue all the time on this forum, but it appears that the issue has been made front and center to the rest of our professional membership.

In his editorial, Dr. Cifu makes several points which warrant further discussion:

1. Inconsistencies in musculoskeletal/interventional spine/sports fellowships lead to problems when it comes to certification of technical profiency/professional competency.

2. PM&R residents “can” and “should” attain adequate skill in the evaluation and management aspect of musculoskeletal/sports/spine medicine during residency, and that additional training in these areas is redundant, if residency training is up to par.

3. PM&R “pain” and “sports” subspecialties were created for political reasons, not because Physiatrists need the extra training.

4. Pain fellowships are being used sub-optimally by future Interventional Spine Physiatrists to provide in-depth procedural training and to affirm proficiency in interventional procedures, the evaluation & management portion is redundant, and that it would be more appropriate for Physiatrists to undergo 1 year of training soley focused on procedural training.

5. PM&R residents should expect to be proficient in musculoskeletal/sports medicine after residency, but should expect that it will take several years in practice for their skills to peak, as in any other specialty of medicine or other professions, rather than expect that a fellowship will bypass this timeline.

These issues have been identified on this forum in other threads.

We’ve got the academy president saying there is a problem.

In the editorial, clear solutions are not offered (maybe to fuel further discussion).

If we acknowledge that not all PM&R residencies provide quality musculoskeletal training, then the use of “can” and “should” (in the editorial) provide adequate musculoskeletal training suggests that many PM&R residencies need to improve and be held to a higher standard.

By the same token, Dr. Cifu suggests that interventional fellowships need to be standardized in procedural content as well as the technical expertise of the trainers.

The question is not so much what to improve as it is how to get the necessary changes implemented.

To current residents, or medical students exploring this specialty who will be affected the most by this issue, in what manner would you like to see the training of musculoskeletal Physiatrists evolve?

Will make for interesting discussion at next year’s annual meeting.
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deja vu all over again
so long as society wants the specialist, is willing to pay for it, and everyone feels entitled to the best damn possible care on the planet even if they're indigent; there will be further specialization training and more degrees. Market forces at work.
Look at general surgery, formerly the uber GI docs. Now we got GI specialists, hell we even have proctologists. Soon we'll have hemorrhoidologists
Hooray for capitalism
 
Gauss said:
deja vu all over again
so long as society wants the specialist, is willing to pay for it, and everyone feels entitled to the best damn possible care on the planet even if they're indigent; there will be further specialization training and more degrees. Market forces at work.
Look at general surgery, formerly the uber GI docs. Now we got GI specialists, hell we even have proctologists. Soon we'll have hemorrhoidologists
Hooray for capitalism
Click to expand...

Sure, why not? We have ortho's who do nothing but replace hips, others just replace knees. There are ophtho's who do nothing but LASIK, because they can. Generalists are an endangered species.
 
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Disciple said:
Anybody happen to read Dr. Cifu's latest "From the President" column in the Physiatrist (AAPMR newsletter)?

We discuss this issue all the time on this forum, but it appears that the issue has been made front and center to the rest of our professional membership.

In his editorial, Dr. Cifu makes several points which warrant further discussion:

1. Inconsistencies in musculoskeletal/interventional spine/sports fellowships lead to problems when it comes to certification of technical profiency/professional competency.

2. PM&R residents "can" and "should" attain adequate skill in the evaluation and management aspect of musculoskeletal/sports/spine medicine during residency, and that additional training in these areas is redundant, if residency training is up to par.

3. PM&R "pain" and "sports" subspecialties were created for political reasons, not because Physiatrists need the extra training.

4. Pain fellowships are being used sub-optimally by future Interventional Spine Physiatrists to provide in-depth procedural training and to affirm proficiency in interventional procedures, the evaluation & management portion is redundant, and that it would be more appropriate for Physiatrists to undergo 1 year of training soley focused on procedural training.

5. PM&R residents should expect to be proficient in musculoskeletal/sports medicine after residency, but should expect that it will take several years in practice for their skills to peak, as in any other specialty of medicine or other professions, rather than expect that a fellowship will bypass this timeline.

These issues have been identified on this forum in other threads.

We've got the academy president saying there is a problem.

In the editorial, clear solutions are not offered (maybe to fuel further discussion).

If we acknowledge that not all PM&R residencies provide quality musculoskeletal training, then the use of "can" and "should" (in the editorial) provide adequate musculoskeletal training suggests that many PM&R residencies need to improve and be held to a higher standard.

By the same token, Dr. Cifu suggests that interventional fellowships need to be standardized in procedural content as well as the technical expertise of the trainers.

The question is not so much what to improve as it is how to get the necessary changes implemented.

To current residents, or medical students exploring this specialty who will be affected the most by this issue, in what manner would you like to see the training of musculoskeletal Physiatrists evolve?

Will make for interesting discussion at next year's annual meeting.
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1) Agree. Huge problem.

2) Agree. The geographic variation in the practice of physiatry, in combination with local coverage determinations, political clout of the SNF coalitions, competing specialists (neurology, rheumatology, Sports-FP) etc makes the specialty practice of physiatry look radically different just based upon *where* you train and practice.

3) Agree. But, those sub-specialties should feed back into general PM&R training experiences. Again, the situation in physiatry is akin to doing an internal medicine residency and never having a nephrology rotation. How can this IM resident possibly ever be competitive for a subsquent nephrology fellowship if their base residency program never exposed them to the fundamentals of dialysis management?

The dirty secret in our specialty is most of our "fellowships" are actually designed for remedial education purposes not to carry well-qualified residents to "the next level" in their training and create a pool of physiatry subspecialists who can be consultants and mentors to physiatry generalists.

4) Agree. See number 3 above.

5) Unclear argument. There is so much wasted time and mis-used time in current PM&R training. How many inpatient deconditioned nursing home bounce-back consults must a physiatry resident do before they are competent? Pick a number: 15, 30, 60? The field agrees on 200 EMGs? How many peripheral joint injections? Etc. The procedural training standards are vague.

Again, the real problem is that most fellowships are being used as remedial education experiences because of perceived core residency training deficits. It's reasonable to expect that residency training in a specialty should prepare the recipient of that training to function like a bonafide specialist in his field. I think that is what patients expect from their residency-trained/fellowship trained specialists and sub-specialists.

Physiatry needs to stop talking to itself and borrow solutions from other specialties. How does dermatology or otorhinolaryngology (ENT) deal with these issues?
 
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It's like the election this year.


Lot's of speeches, rhetoric, etc.


Yeah, the problem has been identified.


I think most of us want to know what the the guys up top plan to do about it.
 
Disciple said:
It's like the election this year.


Lot's of speeches, rhetoric, etc.


Yeah, the problem has been identified.


I think most of us want to know what the the guys up top plan to do about it.
Click to expand...

Every year is election year when your tenure is only 12 months...

Answer to your question can be find in your own line #2.
 
drusso said:
The dirty secret in our specialty is most of our "fellowships" are actually designed for remedial education purposes not to carry well-qualified residents to "the next level" in their training and create a pool of physiatry subspecialists who can be consultants and mentors to physiatry generalists.
...

Again, the real problem is that most fellowships are being used as remedial education experiences because of perceived core residency training deficits. It's reasonable to expect that residency training in a specialty should prepare the recipient of that training to function like a bonafide specialist in his field. I think that is what patients expect from their residency-trained/fellowship trained specialists and sub-specialists.
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Hmm.
I tend to agree with what’s been said here, and I'm pretty sure this is not what the fellowship directors envisioned. Do you think this is the prevailing viewpoint of the PGY-3’s now applying for fellowships? Or are they trying to stay competitive in what they perceive are desirable, competitive areas of PM&R? Does this explain why Mayo residents apply to/get accepted to the Mayo sports fellowship? UMDNJ residents to Stitik/Foye's musculoskeletal fellowship? Cornell residents to the Hospital for Special Surgery spine fellowship? I would like to think that these, and other similar fellowships, are using their programs to take the elite to “the next level”. But how does the field advance and evolve if these graduates shy away from academia, as I’ve seen more than a few of them do?

Do you want to improve residency programs? Get the cream of the crop graduates to stay in academia. Recognize and reward teaching and mentoring. Not just research, not just clinical productivity.
 
Ludicolo said:
Hmm.
I tend to agree with what's been said here, and I'm pretty sure this is not what the fellowship directors envisioned. Do you think this is the prevailing viewpoint of the PGY-3's now applying for fellowships? Or are they trying to stay competitive in what they perceive are desirable, competitive areas of PM&R?
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True.

However, these programs are in the minority. It's like that "only as strong as your weakest link" chiche. Unfortunately, our specialty has alot of weak links.

In my community (specialist saturated), there is a perception by referring Physicians that the first generation outpt Physiatrists (those who set up shop in the area 15+ years ago) don't really do a whole lot, or don't really add anything unique to the evaluation/management of musculoskeletal/pain patients, i.e. no injections, no opiates, MSK skills pretty much the same as the comprehensive pain docs in the area. There are also 2nd generation Physiatrists in the area who offer some injections, a little better MSK evaluation, no opiates, who are held in a little bit higher regard.

It makes the specialty look bad when you have a Physiatrist, who advertises himself as a musculoskeletal specialist, refer complex patients to another musculoskeletal Physiatrist because he doesn't have anything to offer the patient.

Referirng physicians notice this sort of thing.

Regarding academics, research and clinical productivity in academics are rewarded in other specialties, not just ours.

For a spine guy/gal, what are they to do if there is no PM&R spine center at the university hospital in the city in which they want to live? Stands to reason they may join up with the pain department.

If there is no interest in creating a sports component to a PM&R residency, can you blame them for instead joining and working for the ortho dept?

What about an MSK/spine guy who is bringing in substantial revenue to the department through a volume of procedures/EMG, but receives a salary commensurate with those not generating the same in collections, when the offer through another department would likely be substantially higher. Then, throw inpatient call on top of that.

These are real issues that likely play a factor in the decision as to whether a musculoskeletal Physiatrist will stay in academics or not.
 
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I have to say that I enjoyed reading the above mentioned article. It affirmed what I was suspecting in the first place - that the notion of learning after residency is a must.

For example: I will enjoy learning some axial procedures, EMG, disability evaluation, general MSK outpts, and other things during residency. But I'm not sure that I would have to time to become comfortable doing it all. Certainly, in Canada we have a 5 year program that gives us ample elective time to essentially subspecialize during residency (eg. 6 months of EMG experience and write the exam before graduation). However, it seems that many grads now want to learn multiple "subspecialities". I guess I fall into that group.



The efficiency point mentioned by drusso is key to producing good general physiatrists. Increase the quality of education by retaining the "good" residents in academia (as mentioned above) and cut out the redundancy. I guess it's all good in theory. I'm trying to instill the notion in medical students that it's about enjoying the job and not the cash. In Canada we don't have the same rush of grads into interventional procedures. I'm not sure why. Could be a number of reasons - lack of fellowships, already got what they needed in residency, or the over abundance of jobs in an town just waiting to be taken.

The point about general internists was also interesting. They can graduate after 4 years and set up shop doing dialysis, stress tests, read pfts, etc. So what do we consider general standards? Inpatients, msk outpts, emg?

The truth is that we are unique and privileged to have such a broad speciality. Have you ever looked at the list of SIGs? It's huge.
 
Disciple said:
You mean improve residency training?

I think that one gets a "we'll see" from me.
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No I meant "Lot's of speeches, rhetoric, etc."
 
Disciple said:
In my community (specialist saturated), there is a perception by referring Physicians that the first generation outpt Physiatrists (those who set up shop in the area 15+ years ago) don't really do a whole lot, or don't really add anything unique to the evaluation/management of musculoskeletal/pain patients, i.e. no injections, no opiates, MSK skills pretty much the same as the comprehensive pain docs in the area. There are also 2nd generation Physiatrists in the area who offer some injections, a little better MSK evaluation, no opiates, who are held in a little bit higher regard.

It makes the specialty look bad when you have a Physiatrist, who advertises himself as a musculoskeletal specialist, refer complex patients to another musculoskeletal Physiatrist because he doesn't have anything to offer the patient.

Referirng physicians notice this sort of thing.
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This is "spot on." It also gets to the sum and substance of Dr. Cifu's other editorial last month that addresses the widening gab between what academic versus community-based physiatrists actually do. We pretend that our specialty is a monolothic entity united by guiding principles of rehabilitation and functional restoration, but that is poppycock.

We are really a confederacy of niches. We are the "Battlestar Galactica" of medical specialties---a rag-tag fugitive fleet of specialized dabblers, dilettantes, and jack of all trades. We are a "long-tail" specialty.

http://en.wikipedia.org/wiki/The_long_tail

http://www.longtail.com/about.html

To a large degree, the drivers for practice innovation in our specialty do not exist inside our large academic teaching institutions, but in smaller community venues. This is upside from other medical specialties. I think that potential solutions will need to address this reality.
 
Disciple's observation about the 1st generation vs. 2nd generation physiatrists is key and underscores Cifu's 5th point about learning/progressing after residency. Keeping up with the Jones' as it were.

I think that the PM&R higher ups do need to sit down and establish new standards (and better ways to measure them) for residency education - proficiency in MSK examination and diagnosis for example - and set the bar high. Give all programs a time frame to meet the higher standards. If this results in the shutting down some of the weaker programs - not necessarily a bad thing. Save the fellowships for the best of the best. Take 'em to the next level and groom 'em for academia.

I agree that most (not all) of the practice innovators are out in the community, and we in academia need to do a better job at enticing them to contribute to student/resident education. This is obviously not as simple as it sounds due to numerous external/internal geopolitical forces. But can we at least make it more attractive for them to keep a foot in academics? In order to teach and impart their wisdom, these innovators will have to be compensated in some way for the inevitable cut into their time. As I said before, we get paid based on clinical productivity and research productivity. Nobody gets paid for teaching productivity.

Funny - during my residency one of my mentors told me that in order to be happy and successful I should "find my niche". I did and I am happy but - am I contributing to the problem in the long run?
 
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drusso said:
1) Agree. Huge problem.

2) Agree. The geographic variation in the practice of physiatry, in combination with local coverage determinations, political clout of the SNF coalitions, competing specialists (neurology, rheumatology, Sports-FP) etc makes the specialty practice of physiatry look radically different just based upon *where* you train and practice.

3) Agree. But, those sub-specialties should feed back into general PM&R training experiences. Again, the situation in physiatry is akin to doing an internal medicine residency and never having a nephrology rotation. How can this IM resident possibly ever be competitive for a subsquent nephrology fellowship if their base residency program never exposed them to the fundamentals of dialysis management?

The dirty secret in our specialty is most of our "fellowships" are actually designed for remedial education purposes not to carry well-qualified residents to "the next level" in their training and create a pool of physiatry subspecialists who can be consultants and mentors to physiatry generalists.

4) Agree. See number 3 above.

5) Unclear argument. There is so much wasted time and mis-used time in current PM&R training. How many inpatient deconditioned nursing home bounce-back consults must a physiatry resident do before they are competent? Pick a number: 15, 30, 60? The field agrees on 200 EMGs? How many peripheral joint injections? Etc. The procedural training standards are vague.

Again, the real problem is that most fellowships are being used as remedial education experiences because of perceived core residency training deficits. It's reasonable to expect that residency training in a specialty should prepare the recipient of that training to function like a bonafide specialist in his field. I think that is what patients expect from their residency-trained/fellowship trained specialists and sub-specialists.

Physiatry needs to stop talking to itself and borrow solutions from other specialties. How does dermatology or otorhinolaryngology (ENT) deal with these issues?
Click to expand...

I have a "modest proposal" to address the issue of fellowships to correct real/perceived deficiencies in musculoskeletal training. 1) Promulgate rigorous standards for a curriculum for musculoskeletal medicine training; 2) Enforce compliance by the RRC during accreditation; and 3) ONLY permit accredited/compliant programs to train residents. (Of course, I would quickly add that these programs ALSO should be able to comply with standards for training in EDX, and neurorehab fields too).

We would have far fewer physiatry programs if this proposal were implemented, but then those would be very strong programs.

In practice, my modest proposal would not completely solve the problem. Even under the best of training circumstances, clinical proficiency grows with experience, and there will be those who will remain insecure until they have completed further training or have more years of musculoskeletal experience behind them. Moreover, it is not realistic to expect that the specialty would accept my "modest proposal", and downsize the number of residency programs. Perhaps it is thus a good thing that the musculoskeletal fellowships exist, so that there is a clinical/educational option for those graduates unfortunate enough to train in suboptimal musculoskeletal training experiences. For the foreseeable future, the specialty is not going to force all residency training programs to provide excellence in clinical musculoskeletal training experience.
 
ShrikeMD said:
I have a "modest proposal" to address the issue of fellowships to correct real/perceived deficiencies in musculoskeletal training. 1) Promulgate rigorous standards for a curriculum for musculoskeletal medicine training; 2) Enforce compliance by the RRC during accreditation; and 3) ONLY permit accredited/compliant programs to train residents. (Of course, I would quickly add that these programs ALSO should be able to comply with standards for training in EDX, and neurorehab fields too).

We would have far fewer physiatry programs if this proposal were implemented, but then those would be very strong programs.

In practice, my modest proposal would not completely solve the problem. Even under the best of training circumstances, clinical proficiency grows with experience, and there will be those who will remain insecure until they have completed further training or have more years of musculoskeletal experience behind them. Moreover, it is not realistic to expect that the specialty would accept my "modest proposal", and downsize the number of residency programs.

Perhaps it is thus a good thing that the musculoskeletal fellowships exist, so that there is a clinical/educational option for those graduates unfortunate enough to train in suboptimal musculoskeletal training experiences. For the foreseeable future, the specialty is not going to force all residency training programs to provide excellence in clinical musculoskeletal training experience.
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I can't comment on whether other subspecialty fellowships besides MSK or Pain in physiatry are geared more toward advanced practice or remediation, but I suspect that the problem is more widespread than we recognize.

I do agree that unless there exists actual and enforced training standards based upon competency thresholds, primary certification in PM&R is at risk of turning to a "gateway" certificate to other fields: MSK, Pain, Neuromusc/EDX, etc.
 
Gauss said:
so long as society wants the specialist, is willing to pay for it, and everyone feels entitled to the best damn possible care on the planet even if they're indigent; there will be further specialization training and more degrees. Market forces at work.
Look at general surgery, formerly the uber GI docs. Now we got GI specialists, hell we even have proctologists. Soon we'll have hemorrhoidologists
Hooray for capitalism
Click to expand...

That all depends on what kind of specialist you want to be recognized as.

Do you want to be a sports doc? FPs, Internists, ER docs and Pediatricians have this title too.

Do you want to be a pain doc? Anesthesiologists, Neurologists and Psychiatrists have this title too.

Each of these core specialties has its own skill set/knowledge base which defines it, and to fall back on. Physiatry has....oh, wait….Pain management and sports, i.e. all things musculoskeletal is supposed to be your core specialty.

In the long run, if we don't assert ourseleves as the musculoskeletal experts, we put ourselves at a competitive disadvantage, because what do we have to offer that other specialties cannot offer to the musculoskeletal/pain and sports patients, in terms that the general public and medical community can understand?

Why should another physician refer a patient or a patient refer themselves to a PM&R practice vs another practice? After all, pain management is pain management and sports medicine is sports medicine, right?
 
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drusso said:
This is "spot on." It also gets to the sum and substance of Dr. Cifu's other editorial last month that addresses the widening gab between what academic versus community-based physiatrists actually do. We pretend that our specialty is a monolothic entity united by guiding principles of rehabilitation and functional restoration, but that is poppycock.
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The reason I bring this up is that my group receives referrals from MSK Physiatrists when the patients are complex.

The typical consult report reads something like "Recommend home exercise program, referral to pain-management specialist for injections or consideration of intrathecal pump and to assess medication regimen".

Great consult, huh?

So, the patient is not intended to see another Physiatrist, but that's what ends up happening, and then the PCP gets separate progress notes from 2 musculoskeletal Physiatrists. Sometimes, the patient will continue to see Physiatrist #1 for f/u in addition to Physiatrist #2. I can only imagine what the PCPs think when going through the progress notes.

This is not to mention the confusion to the patient. "My primary sent me to see Dr. Smith, who said he was a spine specialist. Well, he didn't really do anything other than to say that he doesn't prescribe pain meds and that I needed to come to your practice."

End of visit: "Nice to meet you Dr. Disciple. So what's your specialty again?"

Me: "Uhhhh……..Pain Management?..........and Physiatry."

Pt: "So, you're a Physiatrist too? Why did I have to see two of you?"

Me: Uhhhh….well…..because

"Sigh"

I think 2nd generation musculoskeletal Physiatrists are probably the norm right now, with the number of Physiatrists who work in Neurosurg/Ortho-spine practices, and that we should be pushing for 3rd generation, i.e. specialists who don't have to depend on referrals intended for other specialists.

Regarding the issue with academics and going back to Dr. Cifu's previous column on PM&R research, a lot of PM&R musculoskeletal/spine/interventional pain research is done through private practice and goes through NASS, ISIS, sometimes PASSOR.

Why?

Because opportunities are not readily available through our academic departments. How many PM&R departments are part of a large spine center, pain program, sports program? A handful? Ten? Fifteen?

It is laudable for Dr. Cifu to put these issues out in the open.

I wonder if he's getting any flack for it?
 
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drusso said:
I do agree that unless there exists actual and enforced training standards based upon competency thresholds, primary certification in PM&R is at risk of turning to a "gateway" certificate to other fields: MSK, Pain, Neuromusc/EDX, etc.
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Like Internal Medicine

The difference is that in IM you still have primary care and have first access to patients. In geographic regions with alot of specialists, with general PM&R, you're limited to community rehab hospitals and SNFs, while still requiring referrals. TBI/SCI is going to be sent to the academic center.

In my community, and I'm sure many others, no one is going to send MSK patients to a Physiatrist unless he/she is a pain physician or a spine/sports guy (or gal).

PM&R EMGs are generated off the MSK patients because the complex studies generally get sent to Neurologists, for work-up/management beyond the EMG.

Heck, I get referrals from PCPs who send alot of their radics first to Neurologists for diagnosis and conservative care, then to surgeons, then to myself under the heading of "pain management", after the patient fails to improve and no surgery is indicated.

It is hard to break these referral patterns. Lots of peer education we need to do.
 
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ShrikeMD said:
In practice, my modest proposal would not completely solve the problem. Even under the best of training circumstances, clinical proficiency grows with experience, and there will be those who will remain insecure until they have completed further training or have more years of musculoskeletal experience behind them. Moreover, it is not realistic to expect that the specialty would accept my "modest proposal", and downsize the number of residency programs. Perhaps it is thus a good thing that the musculoskeletal fellowships exist, so that there is a clinical/educational option for those graduates unfortunate enough to train in suboptimal musculoskeletal training experiences. For the foreseeable future, the specialty is not going to force all residency training programs to provide excellence in clinical musculoskeletal training experience.
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Most viable solutions to political issues require at least some degree of compromise.

I would suggest that the board take the Interventional Spine certification they are considering and create a dual pathway certification process similar to the way in which plastic surgeons are trained, through either residency or residency + fellowship.

This would provide incentive for programs to improve (many strong applicants would choose progressive programs), but would not result in the closure of any programs. Sure, it may make for some uncomfortable residency interviews i.e. applicants asking if they would be eligible for the Interventional Spine boards upon graduation, but that's another issue.

The certification process should include submission of procedure logs/Op-reports as well as a written test and practicum that involves fluroscopic image interpretation (ala EMG waveform practicum for ABEM exam), perhaps including some real-time images of contrast flow.

If a resident graduated from a weak MSK program, he/she could still enter a 1-yr procedural fellowship (as suggested in Dr. Cifu's article) that met certain standards of techinical training and content, and be eligible for the exam upon completion.

The end result, regardless of which training pathway is taken, would be a Physiatrist who would meets certain standards as it pertains to both knowledge, evaluative abilities and technical expertise.

Our best residents and future faculty, if they so desire could train at a strong MSK/interventional residency program followed up by an accredited sports fellowship.

Regarding EMG training, perhaps just tweak it a little, i.e. require 200 studies performed and interpreted (observed studies would not count) and require programs to start using the AANEM TAPSE (spelled right?) in their curriculum. Maybe require a certain number of studies performed for neuromuscular disease, etc.

There are any number of workable solutions out there.

I just hope as much brainstorming is going on at our PM&R organizations as goes on here.
 
>>Regarding EMG training, perhaps just tweak it a little, i.e. require 200 studies performed and interpreted (observed studies would not count) and require programs to start using the AANEM TAPSE (spelled right?) in their curriculum. Maybe require a certain number of studies performed for neuromuscular disease, etc.

I have been pondering the role of neuromuscular for physiatrists. First, it seems there is only one PM&R sponsored neuromuscular fellowship in the country at UC-Davis, yet I often see people add "neuromuscular" to the list of 'physiatry subpecialists', A true neuromuscular specialist will do muscle biopsies, diagnose and manage these diseases. Otherwise it seems we are talking about an electrodiagnostic fellowship. Most of neuromuscular fellowships are run by neurologists and can be 2 years in length. I suppose some would consider taking physiatrists from what i've heard. As far as electrodiagnostic fellowships most are also run by neurology. I spoke to one EMG fellow at an Ivy league institution who told me "we don't really take other fields other than neurology because we are one of the best progs in the country" :smuggrin:
I told him most physiatrists aren't interested in EMG fellowships since we feel confident to diagnosis radics, CTS, etc. and that's what we are usually referred and treat. If there are any neuromuscular physiatrists out there who are specifically referred EMG's to "r/o ALS" please speak up, lol.

The AANEM seems gearing more towards neuromuscular diseases lately (see other thread about AANEM Tpsae) And this goes back to the original header for this therad "MSK fellowships where is physiatry going." While it sounds like a great idea to incorporate an electodiagnostic standard, is AANEM really a general physiatry standard or is it a fellowship trained neuromuscular standard?
 
Hemisphere said:
I have been pondering the role of neuromuscular for physiatrists. First, it seems there is only one PM&R sponsored neuromuscular fellowship in the country at UC-Davis, yet I often see people add "neuromuscular" to the list of 'physiatry subpecialists', A true neuromuscular specialist will do muscle biopsies, diagnose and manage these diseases. Otherwise it seems we are talking about an electrodiagnostic fellowship. Most of neuromuscular fellowships are run by neurologists and can be 2 years in length. I suppose some would consider taking physiatrists from what i've heard. As far as electrodiagnostic fellowships most are also run by neurology. I spoke to one EMG fellow at an Ivy league institution who told me "we don't really take other fields other than neurology because we are one of the best progs in the country" :smuggrin:
I told him most physiatrists aren't interested in EMG fellowships since we feel confident to diagnosis radics, CTS, etc. and that's what we are usually referred and treat. If there are any neuromuscular physiatrists out there who are specifically referred EMG's to "r/o ALS" please speak up, lol.

The AANEM seems gearing more towards neuromuscular diseases lately (see other thread about AANEM Tpsae) And this goes back to the original header for this therad "MSK fellowships where is physiatry going." While it sounds like a great idea to incorporate an electodiagnostic standard, is AANEM really a general physiatry standard or is it a fellowship trained neuromuscular standard?
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You bring up a good point. As drusso pointed out above, we don't want PM&R becoming a gateway specialty, because we're specialists, and specialists generally need referrals.

I think we have to be careful not to allow Neuromuscular fellowships be used as an EMG qualifier the same way we use pain fellowships as Interventional Spine/MSK qualifiers.

How many PM&R docs do you know who would do a 12 month Neuromuscular fellowship, just to prove that they can do EMGs competently, in addition to their extra training in sports, spine, pain, or whatever? It's not practical.

The vast majority of Neurology EMG fellowships are Neurophysiology fellowships and lead to the ABPN Neurophysiology subspecialty certification. A small number are actual Neuromuscular fellowships and are designed to train physicians who will fully evaluate, work-up and treat patients with Neuromuscular disease.

As a community Physiatrist, it is rare that you will have EMG referrals for these types of patients unless you build a Neuromuscular disease practice, are a Pediatric Physiatrist or work in an MDA clinic.

The idea is to set high, concrete standards for PM&R EMG training so that there will be no doubt about a Physiatrist's electrodiagnostic skills upon graduation from residency.
The reality is that many programs provide weak, truncated or incomplete EMG training.
As stated in Dr. Cifu's article, the idea is to eliminate redundancy in our training, which is what happens when every different skill requires it's own fellowship. How to do that while raising the training standards is the million dollar question.

The AANEM TPSAE is a tool that can be used by PM&R residencies to gauge whether the training they are providing their residents with is up to par, and would likely be far more useful than whatever EMG questions are included on the SAE each year. So, the idea is not to force more Neuromuscular training upon PM&R residents, but to make newly graduated Physiatrists uniformly competitive in the arena for EMG referrals, even if those referral are usually for radics and peripheral nerve entrapments.

If we really wanted to mess things up, we could fragment the specialty enough so that one would have to pass their PM&R boards followed by Pain fellowship, Neuromuscular fellowship and Sports fellowship just to have a run-of-the-mill musculoskeletal or Sports & Spine practice. Anybody want to spend 7 years in post-grad training?
 
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Hemisphere said:
If there are any neuromuscular physiatrists out there who are specifically referred EMG's to "r/o ALS" please speak up, lol.
Click to expand...

I consider myself a neuromuscular physiatrist, among other things. I'm in academia. Did an EMG fellowship (neuro based – at one of the other “best progs in the country”), before there were such things as “neuromuscular fellowships”. If you want, I can talk to the Ivy League EMG fellow and knock him down a peg or two… :D

I do get the r/o ALS, LEMS, plexopathy, etc. referrals, and short of performing biopsies I can do the whole diagnose and treat thing, including treatment from the rehab perspective. Got the practice set up where PM&R is the primary EMG presence at the institution, rather than neurology (!) I do realize however that I’m in a rather unique situation.

Disciple said:
The idea is to set high, concrete standards for PM&R EMG training so that there will be no doubt about a Physiatrist’s electrodiagnostic skills upon graduation from residency.
The reality is that many programs provide weak, truncated or incomplete EMG training.
Click to expand...

100% agree.

I like the idea of using the TPSAE. There is actually a recent article suggesting a correlation between TPSAE score and passing the ABEM test.
 
I think a lot of programs with good EMG training have good relationships between Neurology and PM&R departments. At RIC, I have done r/o ALS studies with my physiatrist attendings at RIC and r/o ALS studies with neurologist attendings at Northwestern. We have a lot of collaborative efforts between departments - my program director has clinic with a neurologist for ALS and post-polio patients. We residents rotate through their EMG lab, ALS, MDA, and other clinics and work with the Univ of Illinois Chicago fellows at the VA on EMGs. There are about 6 attendings at RIC who do EMGs - 2-3 of them at the sports and spine center and the other half at the inpatient facility. This gives us exposure to a nice variety of cases including radics, CTS, ALS, myopathies, brachial plexopathies, etc. Having exposure to those 6 physiatrists, 1 physiatrist who does single fiber EMG, 3 neurologists at the VA and 3 neurologists at Northwestern also gives us exposure to a wide array of ways to do electrodiagnostic studies. We host an annual electrodiagnostic conference that attracts neurologists and physiatrists from all over the country (helps with the AANEM board exam) featuring prominent electrodiagnosticians like Dr. Kimura, Dr. Robbinson, etc. We also take the EMG SAEs every year and go over the answers with our attending. When we do our "senior EMG" rotation, we teach junior residents which really has helped me learn my EMG as well as learning teaching skills.

I definitely agree with disciple that we need to set our standards high. I think there is too much variability within PM&R residencies and that some of the "sub-par" ones just need to be shut down. Every year, we debate about how to attract better students, how to increase our average board score, how to make our specialty more competitive. I know some will argue that closing down programs will only decrease the number of physiatrists thereby decreasing our visibility and overall political power - but I argue that having sub-par and borderline incompetent physiatrists represent the specialty does not serve us well. One BAD physiatrsts can ruin the perception of the field because our field is so small. Most non-physiatry docs only know one or two physiatrists - it's like being a racial minority - unfortunately, the actions of a few bad "representatives" can hurt the reputation of a whole group of people especially when there is widespread ignorance and misconceptions about our field.

I also think that residency programs (ACGME RRC and ABPMR as well) need to equip physiatrists with the skillset needed to be a competent and well-respected physiatrist. There should be a consensus on what is considered basic fundamental knowledge for a physiatrist - (MSK exam skills, peripheral joint injections, basic spine injections, EMG, botox, etc.) and that needs to be taught at each residency program (maybe have a standard curriculum - kind of like the PASSOR MSK exam guide) with specific details about the depth and breadth of the training. (i.e. need to see a certain number of neuromuscular dx, etc.) We should be keeping logs of the types of patients we see, types of procedures we perform, types of complications managed, etc. We also need to be taught how to do disability evaluations, etc. Anything beyond the basics we should have fellowships (advanced pain procedures, advanced neuromuscular dx and treatment, sports team coverage, etc.)

Unfortunately, the people who think this way are mostly in the AAPM&R which represents all physiatrists - majority of whom are in private practice and therefore know the marketforce and demand. Those who really need to think this way but don't are mostly in the AAP, part of the ABPMR, etc. There's some cross-communication between groups but the mission and vision of each group differs. For example, the ABPMR's main purpose is to serve the public (protect patients, etc.) so the fact that it's inconvenient for us to have the board exam in August does not really matter to them because we do not represent who they serve. I'm not sure how politically to unite all the power players in physiatry to share the same goal to further the field but it needs to be done.
 
So offering more and better services is not serving the public?

Isn't there some liason between the AAPMR and ABPMR/AAP?

All the hearsay sounds like they have made some of the appropriate steps (sports med boards), and are considering others, but why not just create a committee within the AAPMR (MSK, spine/pain, sports, EMG, Peds, Neurorehab-TBI/SCI reps) that reports/conferences annually/bi-annually with the AAP/ABPMR to let them know what's going on in the communities, and for strategic planning?

Isn't that supposed to be one of the goals of the new & improved AAPMR? Better communication?
 
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There are liaisons btwn the organizations and some AAPMR leaders are leaders in other organizations. I got to talk to ABPMR board members because they were invited to AAPMR functions. That's where they educated me about the difference in mission/vision, etc. The ABPMR board is mainly concerned about patient safety - not so much skill sets, etc. I think our field is behind others when it comes to standards, etc. We JUST went to a more standardized method of oral examination a few years ago - until then, the examiners could ask about whatever they wanted. The written exams obviously feature LOTS of repeat questions - hense the issue of "cheating" and old exam questions. Kind of makes you wonder about the true value of Elkins award.

I actually think the AAP should be doing more - and there's some movement towards incorporating more MSK training, etc. I think there's some thought that inpatient rehab and outpatient MSK are mutually exclusive and attention and time paid to outpatient MSK will mean less for inpatient - which I dont' think needs to be true. Our fund of knowledge, neuromuscular exam skills, disability/impairment/funcational evaluation skills, etc. can be utilized in both settings and many people go into practice doing both inpatient rehab and outpatient clinics. (better to stay diversified) The AAP is working on a standard curriculum for MSK topics. A few years ago a few sdners made a presentation to program directors and chairs about interventional training during residency (which although received well didn't produce much change).

There are definitely efforts. Just not quite enough yet to produce the kind of momentum for change. It will take the retirement of some of the more prominent old school academic leaders to change the mentality of the field. The more progressive ones (like Cifu - who's the chair of the dept, known in TBI, but embracing interventional spine/pain) will lead the way. We just need to continue to push for change. It helps when we tell PDs that med students/applicants are looking for interventional training during residency in addition to a well-rounded curriculum. Certainly has helped with RIC - we lost an interventional opportunity but gained very nice opportunities because the residents did the leg work to build relationships and set up rotations and we made the point that applicants look for those opportunities.

The change needs to come from the ACGME RRC and that will take a while.
 
axm397 said:
There are liaisons btwn the organizations and some AAPMR leaders are leaders in other organizations. I got to talk to ABPMR board members because they were invited to AAPMR functions. That's where they educated me about the difference in mission/vision, etc. The ABPMR board is mainly concerned about patient safety - not so much skill sets, etc. I think our field is behind others when it comes to standards, etc. We JUST went to a more standardized method of oral examination a few years ago - until then, the examiners could ask about whatever they wanted. The written exams obviously feature LOTS of repeat questions - hense the issue of "cheating" and old exam questions. Kind of makes you wonder about the true value of Elkins award.
quote]


i was pretty embarrassed by the board testing process. the written exam was very vague and very similar to old SAEs. the oral exam was a joke. i feel like i could have passed it BEFORE residency. i am not tooting my own horn here, either. i kind of wanted a test that was a bit more specific, and one that you couldnt BS your way thru.

i have definitely come to the realization that board exams, USMLEs, etc are meant to weed out the really poor candidates who have no business in medicine or at least need some remedial work, rather than to maintain a standard of quality. this is fine, but that leaves the burden of turning out good physiatrists on the residency programs, and they continue to fail at this task on the whole.
Click to expand...
 
axm397 said:
There are liaisons btwn the organizations and some AAPMR leaders are leaders in other organizations. I got to talk to ABPMR board members because they were invited to AAPMR functions. That's where they educated me about the difference in mission/vision, etc. The ABPMR board is mainly concerned about patient safety - not so much skill sets, etc. I think our field is behind others when it comes to standards, etc.
Click to expand...

That doesn't really make sense to me. Physiatry doesn't exactly rank really high when it comes to malpractice premiums.

Anyway, isn't protecting the public the job of the state medical board? and what better way to protect the public then to ensure that every Physiatrist who is board certified possesses a certain level of skill and competency?

You mentioned mission and vision. So what is the vision of the ABPMR as it compares to the vision of the AAPMR?

I don't really agree that MSK and inpt can be all mixed together in most competitive geographic regions. Most competitive areas have alot of specialists, so to get referrals, you're going to have to be a specialist as well, with just as many, if not better skills, to make up for the lack of specialty recognition.

What I think the misconception is, is that Neurorehab has to be "inpatient".
Personally, I learned alot more about neurorehab in clinic, taking time to interact with patients and families than I did doing inpt consults on deconditioned patients who couldn't get into a SNF because it was the middle of the winter.
 
Disciple said:
You mentioned mission and vision. So what is the vision of the ABPMR as it compares to the vision of the AAPMR?
Click to expand...

ABPMR:
The mission of the American Board of Physical Medicine and Rehabilitation is to enhance the quality of health care available to the public by maintaining high standards for physiatrists and subspecialists through a certification and Maintenance of Certification© process designed to foster and assess medical knowledge, judgment, professionalism, clinical and communication skills, and to encourage continuous learning.

Vision:to promote quality patient care among physicians in the specialty of physical medicine and rehabilitation.


AAPMR
Mission Statement
The American Academy of Physical Medicine and Rehabilitation serves its member physicians by advancing the specialty of physical medicine and rehabilitation, promoting excellence in physiatric practice, and advocating on public policy issues related to persons with disabling conditions.

Vision Statement
The American Academy of Physical Medicine and Rehabilitation will be the leader in assisting PM&R physicians to acquire the continuing education, practice knowledge, leadership skills, and research findings needed to provide quality patient care, and to represent the best interests of patients with, or at risk for, temporary or permanent disabilities.

AAP
Society Information
"The mission of the Association is to promote excellence in education, research, and the practice of Physical Medicine & Rehabilitation with the academic arena."

Purpose Statement (Dated: October 14, 2006)
"The purpose of the AAP is to Advance Academic Physiatry by providing Leading Edge Programs, Products, and Services."

Our Goals
The AAP will be:

Goal A - Its members’ indispensable resource for academic development.

Goal B - A leading partner in the advancement of rehabilitation research capacity.

Goal C - The authority and advocate for academic physiatry’s critical role in undergraduate medical education, including training and evaluation.

Goal D - The primary resource for physiatric graduate medical education, including training and evaluation.
 
Disciple said:
What I think the misconception is, is that Neurorehab has to be "inpatient". Personally, I learned alot more about neurorehab in clinic, taking time to interact with patients and families than I did doing inpt consults on deconditioned patients who couldn't get into a SNF because it was the middle of the winter.
Click to expand...

This was a major criticism I had in residency too. Most PM&R residents only see the earliest phases of TBI and SCI recovery. I had only a very limited understanding of what patients must do to actually *live* with their disabilities after they left the inpatient rehab unit. It was all sort of abstract and other-worldly---they'll need a Hoyer lift at home....yeah, right...Do you really have any idea what people have to do to accomodate an apparatus like a Hoyer lift *INSIDE* their homes???? You can't just park that next to the blender...

I think it comes back to the economics of GME. Hospitals are paid to train house-staff to work *in hospitals.* Only family medicine, pediatrics, psych, and ob-gyn gets special permission from the feds to get paid for resident work in the outpatient setting. Since most patients with disabilities actually live outside of rehab hospitals, PM&R training needs to be more focused on outpatient training venues. Outpatient does not equal MSK/Spine/Sports in this sense.

I'd love to here Shrike's ideas on this one...
 
drusso said:
This was a major criticism I had in residency too. Most PM&R residents only see the earliest phases of TBI and SCI recovery. I had only a very limited understanding of what patients must do to actually *live* with their disabilities after they left the inpatient rehab unit. It was all sort of abstract and other-worldly---they'll need a Hoyer lift at home....yeah, right...Do you really have any idea what people have to do to accomodate an apparatus like a Hoyer lift *INSIDE* their homes???? You can't just park that next to the blender...

I think it comes back to the economics of GME. Hospitals are paid to train house-staff to work *in hospitals.* Only family medicine, pediatrics, psych, and ob-gyn gets special permission from the feds to get paid for resident work in the outpatient setting. Since most patients with disabilities actually live outside of rehab hospitals, PM&R training needs to be more focused on outpatient training venues. Outpatient does not equal MSK/Spine/Sports in this sense.

I'd love to here Shrike's ideas on this one...
Click to expand...

Amen, Dr. Russo (and Disciple), Amen.

You have touched upon some of the reasons that outpt neurorehab sometimes gets short-shrift. In my "younger days", when I worked with residents on a daily basis, the residents would sometimes share their discomfort (relative to inpt) at seeing outpts in clinic with me. Part of it was the challenge of balancing the time requirements of inpatient and outpt duties; neurorehab rotations can be busy. Most of the concern, however, was that it can be challenging to step into the continuity of outpt care that has already been provided, become familiar with the patient, and then with their ltd outpt experience try to direct the exam and history in the "right" direction with the time remaining for the outpt visit. It is easy to feel overwhelmed when the residents are out of their inpt/hospital-based element. Of course, that is one notable reason why the exposures need to be integrated into outpt neurorehab training. Yes, I would start the rotations with a review of the "targeted" outpt history & exam for the pt population in question (BI subpopulations mostly-TBI, ICH, CVA, SDH, SAH, tumor, etc.), but learning to tailor the potentially broad physiatric exam, and the multiple things that can be wrong with the BI pt (HA, MSK, CNS/neuro, cognitive, behavioral, social, eqpt) into a reasonable time frame is challenging. Even now, MY exams can take longer than planned--for the resident this is a bigger challenge. This time element of reviewing the relevant hx/exam with the resident, coupled with the poor reimbursement/time with many of these pts (medicaid, charity, MC) are major "stressors" on this important aspect of resident neurorehab training.

Another challenge involves the reality that during a "conventional" two or even three month rotation, the resident will probably NOT see a patient they admitted to rehab again as an outpt. They will see outpts, but outpts that were seen initially as inpts by other residents. The continuity aspect can be appreciated, but not as easily as when one has followed the same patient through the recovery process.

As time passed, I identified some ways to address some of these concerns. On the day before a clinic (I had 4 half-day outpt clinics), I would scan the names of the patients, identifying ones most suitable (and unsuitable) for illustrating continuity concepts/outpt related problems. I would then be able to prepare the resident in advance regarding what to expect, and what I hoped would be observed and covered during their evaluation of the patient. This relieved some of the time pressure, and some of the discomfort that the residents experienced.

I also found that the spasticity clinics were embraced with a lot of enthusiasm by residents of all inclinations (general, MSK, neurorehab). Non-neurorehab oriented residents often found that there was a fair amount of MSK/pain issues to address, and they seemed to enjoy both the procedures and the process of determining which interventions/muscles would best be used for a particular patient. Spasticity clinics also provide an opportunity to address other issues important to the neurorehab patient as well, so they can be useful neurorehab learning exposures for non-"spasticity" related issues (gait, UE fxn, eqpt, medication mgt, skin, goal-setting). Coming back to the original point that prompted the response, spasticity/motor clinics provide a lot of outpt neurorehab continuity of care-->hopefully, residency programs are utilizing them for training purposes beyond "just" shots & pump refills.
 
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axm397 said:
ABPMR:
The mission of the American Board of Physical Medicine and Rehabilitation is to enhance the quality of health care available to the public by maintaining high standards for physiatrists and subspecialists through a certification and Maintenance of Certification© process designed to foster and assess medical knowledge, judgment, professionalism, clinical and communication skills, and to encourage continuous learning.

Vision:to promote quality patient care among physicians in the specialty of physical medicine and rehabilitation.


AAPMR
Mission Statement
The American Academy of Physical Medicine and Rehabilitation serves its member physicians by advancing the specialty of physical medicine and rehabilitation, promoting excellence in physiatric practice, and advocating on public policy issues related to persons with disabling conditions.

Vision Statement
The American Academy of Physical Medicine and Rehabilitation will be the leader in assisting PM&R physicians to acquire the continuing education, practice knowledge, leadership skills, and research findings needed to provide quality patient care, and to represent the best interests of patients with, or at risk for, temporary or permanent disabilities.

AAP
Society Information
"The mission of the Association is to promote excellence in education, research, and the practice of Physical Medicine & Rehabilitation with the academic arena."

Purpose Statement (Dated: October 14, 2006)
"The purpose of the AAP is to Advance Academic Physiatry by providing Leading Edge Programs, Products, and Services."

Our Goals
The AAP will be:

Goal A - Its members’ indispensable resource for academic development.

Goal B - A leading partner in the advancement of rehabilitation research capacity.

Goal C - The authority and advocate for academic physiatry’s critical role in undergraduate medical education, including training and evaluation.

Goal D - The primary resource for physiatric graduate medical education, including training and evaluation.
Click to expand...


These sound more similar to me than different. Would be nice if everybody was more on the same page.
 
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