AAPMR Member Councils vs SIGs

[ShrikeMD]

Did anyone read their AAPMR Connection today?

It looks like the days of the SIGs are numbered, to be replaced by "Member Councils".

These 5 councils are:
1. CNS Rehabilitation

2. Musculoskeletal Medicine (PASSOR's presumptive council)

3. Medical Rehabilitation (the "etc." group)
Encompasses all rehabilitation issues not identified in other councils,

4. Pain Medicine/Neuromuscular Medicine (who came up with this pairing? Does ALS belong with acute/chronic pain medicine? Shouldn't pain fit better with MSK?

5. Pediatric Rehabilitation/Developmental Disabilities
It looks like they left the Peds people to themselves.

At first glance, I don't like it, for a number of reasons. Speaking as someone who strongly identifies with the need to develop Brain Injury Medicine as a subspecialty, I think this will not help the effort, and potentially hinder it. (I recognize that this change wasn't implemented specifically with brain injury medicine in mind, but perhaps falls under the "unintended consequences" category.) Unlike some other neurorehab physiatric subspecialties (such as SCI), BI medicine subspecialists really have no forum/meeting to call their own. (Don't tell me about NABIS/IBIA-->any "scientific" meeting that is ALWAYS preceded by a legal "workshop" for attorneys is a sham.) The BI SIG was never much of a forum (as compared to a free-standing conference/meeting), but it was a very active group that was certainly better than nothing. Now we have nothing (I think).

That is my biased view as seen through the prism of a BI Medicine doc. I am genuinely curious how the rest of my colleagues with other areas of interest in this forum view these changes.

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[Disciple]

Shrike,

Out of curiosity, why do we have a SCI subspecialty, but not brain injury?

Is it the existing body of medical literature on the subjects?

 

[ShrikeMD]

Shrike,

Out of curiosity, why do we have a SCI subspecialty, but not brain injury?

Is it the existing body of medical literature on the subjects?

I can think of several reasons, the most important of which revolve around 1) the relative maturity of the subspecialty (clinically, scientifically, and organizationally/politically [e.g. ASIA], SCI medicine is considerably more mature than BI medicine); 2) the # of fellowships that exist to satisfy subspecialty recognition requirements (spinal cord had several VA-sponsored fellowships, and pediatric rehab was allowed to count both pediatric and physiatric fellowship programs for their numbers); and 3) the "political" (interspecialty) willingness to concede the subspecialty to our (physiatric) sponsorship.

In fairness, the burden of developing the subspecialty of BI medicine should be borne primarily upon those of us practicing in the field (including like-minded neurology/neurorehab docs), and we should not wait for the ABPMR/AAPMR to achieve this for us. Still, we can use all of the help we can get.

I wish we could take a few pages out of the playbooks of our colleagues in PASSOR or ASIA to help realize some of these goals.

 

[ShrikeMD]

Shrike,

Out of curiosity, why do we have a SCI subspecialty, but not brain injury?

Is it the existing body of medical literature on the subjects?

Disciple,

What do you think about combining pain medicine with neuromuscular medicine? I think it is an odd pairing.

 

[Disciple]

I think Musculoskeletal and Pain Medicine should be combined, because realistically speaking, 90+% of Physiatrists who practice "Pain Medicine" do so in the context of Musculoskeletal Medicine.

Most of these PM&R practices basically fit into 1 of 2 categories: more musculoskeletal/EMG + some basic interventional procedures, vs. refractory chronic pain (including musculoskeletal pain, but less focused on diagnosis (less EMG) and more on symptom control) + opiates + higher volume and more advanced interventional procedures.

Some Physiatrists are involved with "functional restoration" programs, where their role is not really to practice musculoskeletal medicine, do procedures or prescribe medications, but to oversee the "team".

These are few and far between in community settings.

Neuromuscular Medicine really fits a little bit into CNS rehabilitation, a little bit into Pediatric Rehabilitation, and a little bit into, I don't know. Maybe there should be a council called "Electrodiagnostic Medicine" in place of "Neuromuscular Medicine", so specific management of different pathologies categorized under Neuromuscular Disease can be left to the various councils (MSK, Peds, CNS). Personally, I don't know of any Physiatrists who have full time Neuromuscular Disease clinics or who spend substantial time in MDA clinics.

I think the concept of "councils" is a good idea because it allows whatever project or political movement your SIG is working on to carry the stamp of approval of the entirety of the specialty's professional organization.

Strength in numbers I suppose.

I'm just not sure the "councils" have been named/grouped as best they could be.

Anybody know if the academy is taking comments from the membership on this, or is this a done deal?

 

[ShrikeMD]

I think Musculoskeletal and Pain Medicine should be combined, because realistically speaking, 90+% of Physiatrists who practice "Pain Medicine" do so in the context of Musculoskeletal Medicine.

Most of these PM&R practices basically fit into 1 of 2 categories: more musculoskeletal/EMG + some basic interventional procedures, vs. refractory chronic pain (including musculoskeletal pain, but less focused on diagnosis (less EMG) and more on symptom control) + opiates + higher volume and more advanced interventional procedures.

Some Physiatrists are involved with "functional restoration" programs, where their role is not really to practice musculoskeletal medicine, do procedures or prescribe medications, but to oversee the "team".

These are few and far between in community settings.

Neuromuscular Medicine really fits a little bit into CNS rehabilitation, a little bit into Pediatric Rehabilitation, and a little bit into, I don't know. Maybe there should be a council called "Electrodiagnostic Medicine" in place of "Neuromuscular Medicine", so specific management of different pathologies categorized under Neuromuscular Disease can be left to the various councils (MSK, Peds, CNS). Personally, I don't know of any Physiatrists who have full time Neuromuscular Disease clinics or who spend substantial time in MDA clinics.

I think the concept of "councils" is a good idea because it allows whatever project or political movement your SIG is working on to carry the stamp of approval of the entirety of the specialty's professional organization.

Strength in numbers I suppose.

I'm just not sure the "councils" have been named/grouped as best they could be.

Anybody know if the academy is taking comments from the membership on this, or is this a done deal?

From what I understand, it is a done deal.

I hope you are right regarding the increased influence potentially attainable with the larger councils. My fear is that it will merely serve to further dilute the limited influence some of the constituencies/subspecialties already have.

 

[SSdoc33]

Did anyone read their AAPMR Connection today?

It looks like the days of the SIGs are numbered, to be replaced by "Member Councils".

These 5 councils are:
1. CNS Rehabilitation

2. Musculoskeletal Medicine (PASSOR's presumptive council)

3. Medical Rehabilitation (the "etc." group)
Encompasses all rehabilitation issues not identified in other councils,

4. Pain Medicine/Neuromuscular Medicine (who came up with this pairing? Does ALS belong with acute/chronic pain medicine? Shouldn't pain fit better with MSK?

5. Pediatric Rehabilitation/Developmental Disabilities
It looks like they left the Peds people to themselves.

At first glance, I don't like it, for a number of reasons. Speaking as someone who strongly identifies with the need to develop Brain Injury Medicine as a subspecialty, I think this will not help the effort, and potentially hinder it. (I recognize that this change wasn't implemented specifically with brain injury medicine in mind, but perhaps falls under the "unintended consequences" category.) Unlike some other neurorehab physiatric subspecialties (such as SCI), BI medicine subspecialists really have no forum/meeting to call their own. (Don't tell me about NABIS/IBIA-->any "scientific" meeting that is ALWAYS preceded by a legal "workshop" for attorneys is a sham.) The BI SIG was never much of a forum (as compared to a free-standing conference/meeting), but it was a very active group that was certainly better than nothing. Now we have nothing (I think).

That is my biased view as seen through the prism of a BI Medicine doc. I am genuinely curious how the rest of my colleagues with other areas of interest in this forum view these changes.

im really not sure what they are trying to achieve with this new development. i see a whole bunch of people who will be in council #2 (MSK), and a smattering of docs in the others. i thought we already had a "MSK council" -- its called PASSOR. the same limited number of people who were in the other original SIGs will now gravitate to one of those councils instead. i dont see a big change.

pain and neuromuscular med doesnt make sense. you'll be putting electromyographers in with pain specialists? why?

 

[Ludicolo]

So I go away for a couple of days, and my SIGs no longer exist?

As I interpret it, you can join more than one council. So I see a lot of physiatrists joining both the MSK council and the pain/neuromuscular medicine council. Electrodiagnosticians can join the MSK, the medical rehab, and the pain/neuromuscular councils. I think their goal is: with people joining more than one council, there will be more overlap/cross-pollination, and therefore will serve to promote "unity" within the specialty. Maybe that's why the powers that be divided things up that way.

Regarding achieving PM&R unity - remains to be seen. I can see Shrike being worried about BI getting swallowed up by SCI in the CNS council. The Medical Rehab council (i.e. the outcasts) wiil be made up of people from cancer, cardiopulmonary, geriatrics, amputee, etc. I see that council as being too fragmented to have any impact in the academy. I could potentially see MSK and pain/neuromuscular becoming the dominant councils, as graduates trend toward outpatient practices.

And the non-clinical SIGs have become "virtual, self-sufficient, community networks”? How long will that be sustained...

Wonder how much it'll cost to join a council.

This year’s SIG meetings in San Diego I think will be more interesting than in years past.

 

[axm397]

The SIG transition has been planned for a while and it has been done with the participation of SIG leadership, PASSOR leadership, Membership committee, and the Academy board. There were so many SIGs (some with very few members and very specialized focus - like space medicine) with only 15% of the total membership participating in SIGs at all - this grouping was supposed to help consolidate, create more of a community, and have more direct communication with the Academy staff and board. I was not involved with the grouping but I'm sure there's a good reason why the groupings are the way they are.

The Councils are free and open to anyone. With more participation, councils have the option of developing work groups of those interested in advancing sub-specialty focused issues - which is encouraged by the Academy. The Council will provide a formal communication and planning between the Academy and these membership councils – unlike the SIGs that were originally intended to be strictly self-networking groups.

 

[ShrikeMD]

The SIG transition has been planned for a while and it has been done with the participation of SIG leadership, PASSOR leadership, Membership committee, and the Academy board. There were so many SIGs (some with very few members and very specialized focus - like space medicine) with only 15% of the total membership participating in SIGs at all - this grouping was supposed to help consolidate, create more of a community, and have more direct communication with the Academy staff and board. I was not involved with the grouping but I'm sure there's a good reason why the groupings are the way they are.

The Councils are free and open to anyone. With more participation, councils have the option of developing work groups of those interested in advancing sub-specialty focused issues - which is encouraged by the Academy. The Council will provide a formal communication and planning between the Academy and these membership councils – unlike the SIGs that were originally intended to be strictly self-networking groups.

I certainly hope that the councils choose to pursue the option of developing the work groups to develop the sub-specialty focused issues. Perhaps this would allow us to retain some of the advantages of the SIGs, particularly the more active ones.

As for the SIG transition being planned for a while, that may be, but the AAPMR certainly did not make it widely known among the general membership.

 

[Disciple]

I certainly hope that the councils choose to pursue the option of developing the work groups to develop the sub-specialty focused issues. Perhaps this would allow us to retain some of the advantages of the SIGs, particularly the more active ones.

As for the SIG transition being planned for a while, that may be, but the AAPMR certainly did not make it widely known among the general membership.

OK, so from what I gather from these various announcements, AAPMR/PASSOR newsletters and e-mails from the SIG directors is that this whole formation of "councils" is an attempt to create "PASSOR" type organizations for the major practice focuses represented in the AAPMR, as well as implement a better vehicle for communication and collaboration with the ABPMR.

On one hand, I can see the benefits.

For example, Shrike, say the American Academy of Neurology were to release a position statement on Brain Injury. Who would co-sponsor it, the PM&R Brain Injury SIG?, or would it have more teeth if it were co-sponsored by the "AAPMR Council on CNS Rehabilitation?".

And in the case of PASSOR, I've heard it described as a "super SIG", i.e. not really relevant in big picture of interdisciplinary musculoskeletal care/Occ Med/Pain Management, etc. Maybe that's why Musculoskeletal/Interventional Physiatrists need membership in a requisite 3-5 organizations these days, PASSOR, NASS, ISIS, ASIPP, and throw in AAPM and ACSM for good measure.

Recently, a joint position statement was released by 4 organizations (ASIPP, ISIS, AAPM and NANS) in opposition to the ACOEM Guidelines (Occ med guidelines used nationally to deny patient care, especially in the musculoskeletal arena). PASSOR was not involved in crafting this statement, though intuitively you'd think they would be given the number of Physiatrists who treat workers with musculoskeletal industrial injuries. So, it's either lack of interest, or lack of influence, and personally, I see the formation of official AAPMR Councils (to replace SIGs) as an attempt to grow our influence, and perhaps bring back some of the members we've pushed towards other organizations.

As for being irked about these plans not being made known to the general membership, I agree with you. For the past 12-18 months we've all been hearing about "reintegration" yada, yada. It would have been nice to have at least 30 days of open comments from the membership before final decisions were made.

 

[drusso]

I think that the conjoining of Pain Medicine and Neuromuscular Medicine seems odd...perhaps Pain Medicine should stand alone--as should each of the practice areas actually represented by a ABPMR subspecialty board:

https://www.abpmr.org/certification/subspecialties/index.html

Hospice and Palliative Medicine
Neuromuscular Medicine
Pain Medicine
Pediatric Rehabilitation Medicine
Spinal Cord Injury Medicine
Sports Medicine

One issue I hope that the new membership councils will address is the question, "What is the role and purpose of a physiatric sub-specialist?" Do we really act as consultants/resources for our general physiatry colleagues? I don't really see physiatric subspecialists functioning in the way that medical subspecialists do---ie most nephrologists, cardiologists, intensivists, etc tell me that deep down inside they professionally and politically identify as "internists." Their subspecialty training deepens their affiliation with internal medicine. Cardiologists don't run off and join cardiovascular surgery departments or thoracic surgery departments, but how come so many physiatric sub-specialists find homes in neurology, orthopedics, anesthesiology, neurosurgery, etc?

I think most physiatrists specialize in order to run away from general physiatry. It seems that most physiatric sub-specialists are either dabblers in a particular field or niche or are completely and utterly divorced from the practice of general physiatry. And, with respect to sports, MSK, and pain medicine it seems that many recent residency graduates pursue these fellowships in order to feel like they have bona-fide credentials in what they purportedly already know....

 

[SSdoc33]

I think that the conjoining of Pain Medicine and Neuromuscular Medicine seems odd...perhaps Pain Medicine should stand alone--as should each of the practice areas actually represented by a ABPMR subspecialty board:

https://www.abpmr.org/certification/subspecialties/index.html

Hospice and Palliative Medicine
Neuromuscular Medicine
Pain Medicine
Pediatric Rehabilitation Medicine
Spinal Cord Injury Medicine
Sports Medicine

One issue I hope that the new membership councils will address is the question, "What is the role and purpose of a physiatric sub-specialist?" Do we really act as consultants/resources for our general physiatry colleagues? I don't really see physiatric subspecialists functioning in the way that medical subspecialists do---ie most nephrologists, cardiologists, intensivists, etc tell me that deep down inside they professionally and politically identify as "internists." Their subspecialty training deepens their affiliation with internal medicine. Cardiologists don't run off and join cardiovascular surgery departments or thoracic surgery departments, but how come so many physiatric sub-specialists find homes in neurology, orthopedics, anesthesiology, neurosurgery, etc?

I think most physiatrists specialize in order to run away from general physiatry. It seems that most physiatric sub-specialists are either dabblers in a particular field or niche or are completely and utterly divorced from the practice of general physiatry. And, with respect to sports, MSK, and pain medicine it seems that many recent residency graduates pursue these fellowships in order to feel like they have bona-fide credentials in what they purportedly already know....

Dr. Russo, when are you gonna get off your butt and assume the leadership role in physiatry that we all know you should? i agree 100% with your post

 

[Disciple]

Their subspecialty training deepens their affiliation with internal medicine. Cardiologists don't run off and join cardiovascular surgery departments or thoracic surgery departments, but how come so many physiatric sub-specialists find homes in neurology, orthopedics, anesthesiology, neurosurgery, etc?

Probably the same reason some people have affairs.


If ya ain't gettin it at home......

 

[ShrikeMD]

I think that the conjoining of Pain Medicine and Neuromuscular Medicine seems odd...perhaps Pain Medicine should stand alone--as should each of the practice areas actually represented by a ABPMR subspecialty board:

https://www.abpmr.org/certification/subspecialties/index.html

Hospice and Palliative Medicine
Neuromuscular Medicine
Pain Medicine
Pediatric Rehabilitation Medicine
Spinal Cord Injury Medicine
Sports Medicine

One issue I hope that the new membership councils will address is the question, "What is the role and purpose of a physiatric sub-specialist?" Do we really act as consultants/resources for our general physiatry colleagues? I don't really see physiatric subspecialists functioning in the way that medical subspecialists do---ie most nephrologists, cardiologists, intensivists, etc tell me that deep down inside they professionally and politically identify as "internists." Their subspecialty training deepens their affiliation with internal medicine. Cardiologists don't run off and join cardiovascular surgery departments or thoracic surgery departments, but how come so many physiatric sub-specialists find homes in neurology, orthopedics, anesthesiology, neurosurgery, etc?

I think most physiatrists specialize in order to run away from general physiatry. It seems that most physiatric sub-specialists are either dabblers in a particular field or niche or are completely and utterly divorced from the practice of general physiatry. And, with respect to sports, MSK, and pain medicine it seems that many recent residency graduates pursue these fellowships in order to feel like they have bona-fide credentials in what they purportedly already know....

There are some noteworthy differences between our field and others with respect to subspecialists. First of all, I think we should recognize that this is an evolving phenomenon, even as we "speak", and is subject to influence by payors, payor mandates, as well as evolving patient preferences which may increasingly recognize some value for the physiatrist/physiatry subspecialist. Secondly, the physiatric subspecialty phenomenon didn't evolve in quite the same way as it did in the medical or surgical subspecialties. On the inpatient side, it has likely been a byproduct of larger academic inpatient rehab hospitals-an environment that is different from the acute care hospital delivery model. Some physiatrists evolved to specialize in a particular niche because of interest in that area, coupled with the availability of others who were happier/more comfortable as generalists. The specialists could direct the marketed programs (BI, stroke, SCI, peds, etc.), while the generalists could care for patient populations where the availability/need/interest for specialization was less apparent. Some hospitals/physiatrists probably found it easier to assign a particular subgroup of patients to physiatrists with a particular interest in that field, rather than asking the subspecialty consultant to assist another generalist as embraced by other specialties.

Outpatient physiatric subspecialization probably evolved in a different direction for similar motivations—a desire to work with musculoskeletal/pain/sports patients, and perhaps a preference to leave inpatient rehabilitation practice to those who prefer those settings.

As to the motivation (ie "running away" from general physiatry) or skill levels (ie "dabblers") of the subspecialist, I would prefer to say that the field is broad enough to allow those interested to pursue expertise in one of the many patient populations we serve. Some may be dabblers, but others clearly are serious subspecialists intent on contributing to patient care and the clinical science needed to enhance care for their patients in the future. I am inclined to agree with you that the greater the commitment to the subspecialty, the greater the tendency to be "divorced" from general physiatry.

With regard to the issue of associations with other specialists (ie ortho, neuro, neurosurgery, etc.), I am unsure to what extent physiatrists are different than other specialists. There are other multispecialty hospitals and clinics. For example, tertiary "neuroscience" centers typically have multiple specialties working together→neurology/subspecialties, neurosurgery/subspecialties, +/- psychiatry, physiatry, as well as neuropsychology. Then again, perhaps due to the breadth of our field and backgrounds in interspecialty/interdisciplinary teamwork, we probably make a good fit to work with geriatricians, ortho, peds, neuro, neurosurg, in their settings as well as "our own". I see this as more of a positive factor→we can succeed in both environments, rather than a conscious decision to work apart from physiatry colleagues or departments. Finally, it is a fact that there are not PMR departments in all medical schools, so physiatrists may not have had a choice in affiliating with another academic department.

 

[drusso]

Probably the same reason some people have affairs.


If ya ain't gettin it at home......

That's brilliant! LMAO! Someone should take that analysis to the AAP.

 

[drusso]

There are some noteworthy differences between our field and others with respect to subspecialists. First of all, I think we should recognize that this is an evolving phenomenon, even as we "speak", and is subject to influence by payors, payor mandates, as well as evolving patient preferences which may increasingly recognize some value for the physiatrist/physiatry subspecialist. Secondly, the physiatric subspecialty phenomenon didn't evolve in quite the same way as it did in the medical or surgical subspecialties. On the inpatient side, it has likely been a byproduct of larger academic inpatient rehab hospitals-an environment that is different from the acute care hospital delivery model. Some physiatrists evolved to specialize in a particular niche because of interest in that area, coupled with the availability of others who were happier/more comfortable as generalists. The specialists could direct the marketed programs (BI, stroke, SCI, peds, etc.), while the generalists could care for patient populations where the availability/need/interest for specialization was less apparent. Some hospitals/physiatrists probably found it easier to assign a particular subgroup of patients to physiatrists with a particular interest in that field, rather than asking the subspecialty consultant to assist another generalist as embraced by other specialties.

Outpatient physiatric subspecialization probably evolved in a different direction for similar motivations—a desire to work with musculoskeletal/pain/sports patients, and perhaps a preference to leave inpatient rehabilitation practice to those who prefer those settings.

As to the motivation (ie "running away" from general physiatry) or skill levels (ie "dabblers") of the subspecialist, I would prefer to say that the field is broad enough to allow those interested to pursue expertise in one of the many patient populations we serve. Some may be dabblers, but others clearly are serious subspecialists intent on contributing to patient care and the clinical science needed to enhance care for their patients in the future. I am inclined to agree with you that the greater the commitment to the subspecialty, the greater the tendency to be "divorced" from general physiatry.

With regard to the issue of associations with other specialists (ie ortho, neuro, neurosurgery, etc.), I am unsure to what extent physiatrists are different than other specialists. There are other multispecialty hospitals and clinics. For example, tertiary "neuroscience" centers typically have multiple specialties working together→neurology/subspecialties, neurosurgery/subspecialties, +/- psychiatry, physiatry, as well as neuropsychology. Then again, perhaps due to the breadth of our field and backgrounds in interspecialty/interdisciplinary teamwork, we probably make a good fit to work with geriatricians, ortho, peds, neuro, neurosurg, in their settings as well as "our own". I see this as more of a positive factor→we can succeed in both environments, rather than a conscious decision to work apart from physiatry colleagues or departments. Finally, it is a fact that there are not PMR departments in all medical schools, so physiatrists may not have had a choice in affiliating with another academic department.

You hit the mark, but I think Disciple's explanation was more parsimonious! I think that organized physiatry is ambivalently attached to its subspecialty movement and sentimental about about some bygone era of PM&R that probably never really existed. We're not family practice or general internists so why do we idealize the general practice of physiatry so much? You don't hear radiation oncologists wax nostolgic about "the old ways." If we are more like other hospital "service line" specialties as you suggest--radiology for example--then find me a recent radiology residency graduate who isn't doing a fellowship in MRI, Dx US, Mammography, Neuroimaging, Nuc Med, etc. He or she is either going to a rural practice location or committing career suicide.

If, like other hospital "service line" specialties, the field of physiatry advances based upon the new depth of knowledge excavated by sub-specialty practice and research, then the field should unequivocally embrace and support its sub-specialty movement. Residency applicants should be hand-picked for their interest in specific areas of rehabilitation medicine and their intentions to sub-specialize. In turn, the field should promote sub-specialty training to its residency graduates and sub-specialty training should be tied to research and technological innovation that in turn "feeds" the whole field...

In reality, I think that this is "pie in the sky." Do you think that's what serious residency applicants are saying these days? They're all trained to give a sufficiently neutral answer about "a balanced practice, a little inpatient, a little outpatient, etc." Everyone knows: Don't look too serious about any one particular area of PM&R. Showing up for an interview at some programs proclaiming your deeply committed interest in MSK medicine can be the kiss of death.

Face it: few sub-specialize in physiatry so that their NIH grant applications are more competitive or to be a resource/ROI to hospitals opening new CNS rehab centers, sports medicine programs, etc. The incentives and reasons for sub-specialization in physiatry appear different than for the rest of medicine. Remember, 20 some-odd years ago the PASSOR movement wasn't hailed as a "forward-thinking, innovative group of highly intelligent individuals." I think one past Academy President might have used the term "bandits." But, bygones, be bygones---now, apparently the zeitgiest has changed. If one PASSOR was good, maybe five will be even better.

Can't wait to see!

 

[Disciple]

That's brilliant! LMAO! Someone should take that analysis to the AAP.

Preferably someone with some years who won't be excommunicated because of it.

 

[Disciple]

Shrike,

You gave a good, detailed, politically-correct explanation, but I think that deep down inside, we know that Physiatrists are joining other departments because of opportunities not available in their home PM&R departments (if one exists), and are joining other organizations because these organizations provide education and discussion of issues that are most directly relevant to the clinical practices of these particular Physiatrists.

This separation started off in the 90s with PASSOR. Then, when basic spine injections weren't enough, we moved on to ISIS, NASS and ASIPP. I'm fine with that because these are strong multidisciplinary organizations. Today, you'll probably even see a few Physiatrists going to ASRA. Personally, that's where I'd draw the line as I feel that is the point of no return in regards to a Physiatrist distancing himself from Physiatry.

We can't go back to the way things used to be, and nowadays, it's necessary to subspecialize, especially if you live in a major metropolitan area. In these environments, most of the TBIs and SCIs are going to be at the academic centers, all the spinal injections and Occ med is going to go to the pain/spine guys, EMGs are going to go to the Neurologists, except for those associated with MSK, which will be sucked up by the pain/spine guys. All that will be left will be general inpt rehab jobs, which, in this environment, will be just as narrow a specialty as anything else. Even internists, the "generalists of all generalists" use hospitalists, and you're not going to find FPs delivering babies or doing colonoscopies except in rural areas where there are shortages of specialists.

In acceptance of this reality, I think this whole council system is an attempt by the academy to show a little bit of "unconditional love" to all of us, to welcome us all home, so to speak. It's an attempt to keep everybody together (and probably to keep the specialty from falling apart) while offering something for everybody.

Sounds good on paper, but we've still got to follow through. San Diego will be interesting for sure.