future of PM&R

doubt it. there are a ton of reasons people need rehab besides hip and knee replacements. go to the aapmr website and read a little more about what we do.

 

Trends in the field will continue to favor sub-specialization in physiatry. PM&R base training will serve as a gateway to fields like neurorehabilitation (SCI and Acquired Brain Disorders), musculoskeletal medicine, sports medicine, neuromuscular medicine, pediatric rehabilitation, and pain medicine. General physiatry becomes akin to general internal medicine in terms of relevance and scope of practice.

PASSOR "re-integrates" into the Academy but maintains a vestigial a network of individuals who advise the field on Spine/MSK/Pain/Occ Med issues.

Long-term chronic care and inpatient rehabilitation see a slight uptick due to aging demographics.

Advances in the neuroscience of functional restoration (stem cell science and nerve regeneration), coupled with political action of injured and disabled military personal returning from the battlefield, result in a the creation of an NIH Institute of Rehabilitation. VA hospitals expand PM&R training opportunities.

MSK ultrasound establishes itself as an important tool for physiatrists in diagnosing and treating MSK injuries. Basic MSK training requirements are incorporated into ACGME PM&R residency training competencies some time before the turn of the next century!

Stagnation in academic physiatry continues to weaken PM&R department chairs' institutional clout and reputations as junior physiatrists "abandon ship" and take positions in departments of anesthesiology, orthopedics, and neurological surgery. Progressive chairs who "see the handwriting on the wall" respond in innovative ways to promote faculty development. Traditionalists are left wringing their hands and wondering "what went wrong??..."

 

The in-patient side won't be lost. There will be no shortage of people requiring inpatient rehab services. However, that doesn't mean that it will be attractive to new graduates.

Two things that could renew interest in inpt rehab:

1. Increase in average salary (unlikely, though Physiatrists were all about inpt rehab back in the 80's when the reimbursement was good)
2. Use of mid-levels to share night call, take calls from nurses, H&Ps/discharges and day-to-day dealing with social workers.

The Physiatrist would take on more of a supervisory role. He/she would be able to keep his/her income at a decent level by working in the clinic doing EMGs, CMGs, EMG guided botox, etc., while the mid-levels run the unit (similar to residents).

The Physiatrist could run the team conferences, round 1-2X/week and spend his time thinking up therapeutic interventions i.e. Orthotics, ITB pump, etc.

I'm surprised I haven't seen anybody doing this yet.

Of course anytime you increase use of midlevels, you run the risk of them eventually replacing you. I can see it now. "What do we need to pay a Physiatrist for? We've got NPs with rehab experience (or Medicine docs with CMEs) and a good group of PTs. Besides, this is a community hospital, not a tertiary care brain injury unit".

 

Agree. Happening already.

After graduation, the MSK/pain guys/gals may keep their PASSOR membership but join up with ISIS,NASS,ASIPP and focus their efforts, CMEs through those organizations.

A former classmate of mine who entered Peds fellowship joined up with the national CP societies.

How many recent grads or senior residents have actually kept or plan to keep their memberships in the AAP?

 

Hmmm...

The million dollar question.

Will musculoskeletal medicine become its own subspecialty, or will Physiatrists in general become the de-facto experts in MSK and non-operative spine care? Will neither one happen?

Right now, we say we are, but other physicians don't really think so and the general public still doesn't know what Physiatrists are or do. I'd say we're about half way there. Other docs know we do MSK/spine, but think that we take care of "easy" patients, are limited procedurally and don't really do anything that other docs can't do.

It seems the academy is going for the latter (all Physiatrists are experts in MSK) with the new AAPMR journal "Musculoskeletal and Rehabilitation Medicine", creating a spine track at the AAPMR conference, inviting Dr. Bogduk to speak, etc. Those are all good efforts and should increase the depth of the core PM&R knowledge base. But, ultimately, the most substantial change must occur at the residency level. The medical community and patients will never be convinced that we are the MSK experts if you have a few very skilled practicioners/experts but your average physiatrist is so-so.

That means competencies is specific diagnoses/management and skill sets. Reading CT/MRI, complex spines, failed joint surgeries, basic needle skills, an even deeper knowledge of functional biomechanics and kinematics and ultrasound (if enough Physiatrists ever become experts).

Surverys about residency MSK training have been done, etc. I haven't seen any changes implemented yet. When it comes down to it, PDs and chairmen will just have to step up, make some affiliations, sacrifice some inpt coverage and let their residents get the training they need if this is to happen.

There's the rub.

 

The future is here. I have been in practice for twenty years and see myself as a physiatrist or orthopedic medicine specialist. 100% of my practice has been musculoskeletal including spine and sports med. I however did not get the training during my residency. Back then physiatrists usually treated cva's,
amputations, spinal cord and performed emgs. I took many cme courses and mentored with other specialty physicians.

The most important thing to remember is not to be afraid of stepping out and doing what you want to do. Also never stop learning...

 

my crystal ball says it's getting more subspecialized just like any other field of medicine or science. they just added three new fellowships as well - neurmuscular dz, palliative care, and... what was that third one lol, guess it didn't interest me much...

anyway, think more people going for fellowship training. everyone wants the pain fellowship these days. seems noone wants to do general inpatient stuff anymore. Not that the jobs aren't out there, if you want to do inpatient physiatry you can write yourself a ticket probably. The inpatient rehab attached to the hospital where i am a TY is run by a neurologist b/c they couldn't find a physiatrist to take it... when i said i am going into rehab and might be interested in inpatient tbi or sci, a physiatrist doing trauma consults in the ICU when i was rotating in there said keep in touch if you want a job. keep in touch for 3 years, right lol.

it's not that the field is changing on it's own physiatrists are becoming more picky about where they want to work and also reimbursemnt chngs have a lot do with it too, eg less for general inpt work than previous.

We need to demonstrate the unique skills and knowledge we have as m.d.'s are worth reimbursement to take care of inpatients. hell if you were in a rehab unit and starting having chest pain, fevers, or a re-stroke , or simply had a question about your medications, would you want to be seen by a mid-level who never carried a beeper to handle these things in the middle of the night before? the irony is people think the mid-level's will reduce the cost of health care, but in reality, they will just call in a consult or worse if you are at free-standing call in an ambulence and the patient will get re-admitted to acute for something minor any m.d. could of just handed quickly.