i think that most people agree with the goals and philosophy of inpatient rehabilitation, they just don't like the practice of it. The day to day practice of it straddles the border between "humpty-dumpty medicine" and medical social work. But it didn't always used to be this way.
To understand how things "got this way" you need to understand a little bit of history...sit down and talk to inpatient physiatrists in private practice circa 1980-1995. These were the "golden years." these were pre-stark i (omnibus budget reconciliation act of 1989); pre-prosepctive payment/drg; pre-healths*outh/richard scrushy industry-wide accounting scandal, etc. In short, inpatient rehab made money. I mean mad money ---and not in some convoluted, accrural-based, cost-accounting/cost-shifting way that only 3 phd health economists and stephen hawkins can understand, but in real honest to goodness cash accounting--a penny earned for a penny's work way.
You see in the early 80's "greed was good," we were all living in reagan's "shining city on a hill," and inpatient rehab made money. Get the picture? Rehab hospitals were opening up like starbucks and bursting at the seams with medically straight-forward post-op total knees and hips. Grandma would sooner die than go to a nursing home and the cash-cow rehab hospitals were posh---one private rehab hospital in the mid-west boasted gold-plated faucets...it had to end...and it did.
In the early 1980's, the salary figures for inpatient physiatrists bandied about were, "$10-15k per rehab bed per year that you keep filled." want to make half-a-mill? Keep 40 rehab beds full per year. And, as any recent grad will attest, rounding on 40 medically-stable post-op total knees (with a pa mind you) might take the better part of 2.5 hours.
I did my first rehab rotation as a medical student the summer of 1997 at a private rehab hospital in dallas. It was like showing up the morning after a huge party. The whole field was hung-over. The hand-writing was on the wall: Inpatient rehab was dead. The excesses from the 1980's were going to be repatriated. Cms (formerly hcfa) ran the numbers and rehab was too expensive. There was over-utilization, mis-utilization, and quite frankly out-right fraud. The feds wanted their "40 acres and a mule" and they were going to take it right out the pockets of physiatrists. It was in this climate that most recent grads began their training.
Now patients had to actually "medically qualify" for rehab based upon an arbitrary and more or less capricious set of 18 or so diagnoses. And, you had to fill at least 75% of your beds with these so-called "medically-qualified" patients. Oh, and by the way, we (the feds) would like to engage in a little "risk-sharing" with you physiatrists. We'll pay you up front one lump for your rehab admission and you can "manage the costs" during there entire rehab stay. No more gravy train.
When people get desperate they behave desperately. As residents, it was quite interesting to watch our attendings engage in feats of self-deception and mental gymnastics beyond all belief to "fill those beds." yesterday, mr. Jones couldn't "tolerate 3 hours of therapy," but today lo' and behold he can. Presto! Oh, and now that we're being paid "prospectively" suddenly airline economics begins to make perfect sense: First, sell your beds at best price to the commerical insurance "medically-qualified" customers; then sell your beds to the "break-even" government payors; and finally open the flood-gates and let-in the "all-comers." it's going to cost the same amount of money to fly that plane with the seats empty or full (plus or minus a little fuel difference) so fill those beds!!! Rehab went from premium first-class recuperation to dumping ground...and who bore the brunt of the dump?? Those idealistic, pie-in-the-sky, pre-80 hour work week physiatry residents that's who. Late admissions? No problem. Fill those beds!!! Non-medically qualified medicare patients languishing on surgical wards or snf's? No problem fill those beds!!! Neurosurg needs an extra bed in icu? No problem---just tell the neurosurg pa to write "transfer to rehab." magic happens. Fill those beds!!!
When you let others define what you do you become their little b*tch. So, in order to "fill those beds!!!" there was no "act of kindness" that an accomodating attending physiatrist wouldn't perform for his or her referring "customer." and, in this new ponzi-esque prospective payment scheme, rehab units and rehab hospitals essentially became hospital "loss leader" service lines. Showing up for work every day in such an environment can be a little demoralizing. Demoralized people are not the most inspiring people to work around and residents certainly can tell where they are on the hospital hierarchy---as a specialty and as a resident. It's like showing up every day and just loading the truck. Thus, the mass emigration to outpatient physical medicine.
There a variety of other factors that turn off residents to inpatient rehab. Most programs lack a clear and structured progression of clinical responsibilities for its residents. In many ways, i was doing the same thing at the end of my physiatry residency that i was doing my first week of internship. Physiatry is one of the few specialties that battles its own allied health providers on scope of practice issues. You don't see radiology techs or respiratory techs lobbying for "independent practice" do you? But, you'll see pt's post here from time to time and assert that they believe that hospital-based physiatrists are superfluous. Many of these pt's/ot's, etc eventually climb the ranks of hospital administration and become "program managers" or "admission coordinators" etc. They are valuable team players, but their expertise cannot replace a physiatrist's...
As others have posted, community-based inpatient rehab is a little different from what residents see in the academic medical centers. This is probably because "all politics is local." i still do some inpatient rehab. It's enjoyable because i have control of the situation. I have hospitalists i can consult who are "johnny on the spot" anytime i need them day or night. Try getting a hospitalist to follow a rehab patient at most teaching programs...good luck! And, most importantly, the way i practice medicine is not defined by the whims of others. The patients can come when i decide they are ready to come. If you don't like it, get a new physiatrist.
