Update from AAPMR Annual Meeting (Councils, PASSOR, SIGs, etc.)

[Disciple]

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For anybody who was unable to attend, here is an update on the member Council situation/ PASSOR from the AAPMR meeting in San Diego.

Final Sports SIG Meeting (Summary):

MSK Council= New PASSOR

-The MSK Council Chair and Chair Elect were chosen to facilitate a smooth transition from PASSOR, and to build on the successes of PASSOR

-The Councils will have task specific “work-groups” which will be more action-based compared to the SIGs, and will be formed to accomplish specific tasks that have been identified e.g. Sports work group, spine work-group, etc.

-Point was made that the Councils will be held directly accountable to the Council Advisory Committee and academy Board of Governors, which was not the case with the SIGs.

-The MSK council will consider adopting AIUM Guidelines or may consider creating PM&R Musculoskeletal Ultrasound Guidelines based on the AIUM Guidelines.

-The pass rate for Physiatrists taking the Sports Medicine boards for the first time was considerably lower in 2007/08 compared to other specialties (study up on your IM!).

Final PASSOR Business Meeting (Summary):

-PASSOR Approved fellowships will continue on as "Academy Approved" fellowships, which will eventually be expanded to include other subspecialties that do not have an ABMS certification, e.g. TBI, etc. utilizing the Academy Approved fellowship model of Neurosurgery and Orthopedic surgery.

-The Spinal Procedures Workshops will continue through the MSK Council

-PASSOR will be memorialized through an annual PASSOR Legacy Award

Recap of Discussion prior to vote to dissolve PASSOR:
There was a fair amount of skepticism voiced from a number of established MSK/Interventional Physiatrists in attendance, many of whom have contributed significantly to PASSOR over the years.
A main worry was that the new MSK council would be weak and inactive, as opposed to PASSOR which has a proven track record.
Proponents tried to provide reassurance that the Council system, as constructed, is a 1st approximation, and may be subject to change/re-organization if necessary.
Also emphasized by proponents was the idea the council system was a way to give Physiatry in general a more organized, stronger voice (e.g. the Academy would be able to issue position statements on MSK issues, etc.), and to determine the direction of the Academy through more of a democratic process. The council system would keep everybody together, instead of us all going off and doing our own things in disorganized little groups. Discussion would begin in the councils and eventually make its way up to the Council Advisory Panel where proposals would be become policy.

Final vote had many voting for the dissolution of PASSOR. None voting against, but a significant number abstaining.

Final Pain SIG Meeting (Summary):

The 5 membership councils were created to get more AAPMR members involved in the affairs and activities of the academy, creating more of a democratic process. The current set-up involves some 30+ SIGS with poor membership numbers, and poor attendance at Academy meetings (I can vouch for this as about 8 people showed up to the Pain SIG meeting). In the current system, only PASSOR really had the numbers and structure to affect any meaningful change.

There will be a Council Advisory Panel consisting of the 5 Council chairs/chair-elects, chairs of the Strategic Coordinating Committees of the Board of Governors, the RPC chair, the Academy Executive Director and the Academy President and President-elect.

MSK was split from Pain to make sure a MSK/Pain council did not overpower all other councils. Also, the academy thought there was enough of a difference between the MSK/Interventional Spine/Sports practicioners and the Chronic Pain/Functional Restoration practicioners to make a split.
Issues that were brought up included:

-The need for the creation of Academy endorsed Pain Management Treatment Guidelines

-Continued work on an AAPMR or better yet ABPMR CAQ for interventional procedures

Suggestions from membership included:

1. Creation of a sub-group/sub-council for Interventional Procedures, to exist between the MSK and Pain councils.

2. The need for the MSK and Pain councils to open dialogue/collaborate with other organizations with strong Physiatric representation such as ISIS, ASIPP, AAPM, NASS.

My Personal Thoughts: Mixed feelings. This change does away with PASSOR which was a successful/proven organization with a track record of achievement. The council system theoretically has the potential to reach beyond PASSOR if we stay motivated/active. In addition, it provides opportunity for younger Physiatrists to be involved in the decision making process and the direction of the academy, i.e. each of us can actually vote in our primary councils, we can volunteer for work-groups, etc.
Final note: The final Richard and Hinda Rosenthal Foundation Lecture was given by Michael Schaufele, M.D. advocating for the Multidisciplinary Spine Center to become the preferred future model for Interdisciplinary Musculoskeletal Care, in addition to advocating for quality MSK education in PM&R residencies, equipping Physiatrists with the skills necessary to thrive in such a model, and the value of a Physiatrist as the first line provider for musculoskeletal and spine care.


So there it is.


Thoughts?


Anyone who attended the other SIG meetings, feel free to add to the thread.

 

[ShrikeMD]

Final PASSOR Business Meeting (Summary):

-PASSOR Approved fellowships will continue on as "Academy Approved" fellowships, which will eventually be expanded to include other subspecialties that do not have an ABMS certification, e.g. TBI, etc. utilizing the Academy Approved fellowship model of Neurosurgery and Orthopedic surgery.

Forgive my interest in a part of the statement that is not part of the central PASSOR theme, but does this suggest that the AAPMR has no plans to pursue/support ABMS certification in BI Medicine?

If so, this would be disappointing.

 

[Disciple]

I think they're just trying to put something in place, independent of what the ABPMR might do.

That is one definite area where there could be better communication, ABPMR to ABPMR Diplomates.

 

[PMR 4 MSK]

Forgive my interest in a part of the statement that is not part of the central PASSOR theme, but does this suggest that the AAPMR has no plans to pursue/support ABMS certification in BI Medicine?

If so, this would be disappointing.

Not to be taken negatively toward you or the field of BI, but how many subspecialties are we going to certify within PM&R? Is this the future of other fields of medicine - subspecialty boards for all the areas of interest/specializaion?

Certainly each subspecialty can be vastly different. I no longer keep up on the literature for BI, SCI, CVA, etc, even though I know it's going to bite me in the butt for recertification. I would not even try to do these fields any longer, it takes all the time I have to keep up with what I do.

My thoughts on this are further divided by the fact I know it shows expertise in the subspecialty and helps advance the field further, but at the same time it seems to divide a fragile specialty further.

 

[ShrikeMD]

Not to be taken negatively toward you or the field of BI, but how many subspecialties are we going to certify within PM&R? Is this the future of other fields of medicine - subspecialty boards for all the areas of interest/specializaion?

Certainly each subspecialty can be vastly different. I no longer keep up on the literature for BI, SCI, CVA, etc, even though I know it's going to bite me in the butt for recertification. I would not even try to do these fields any longer, it takes all the time I have to keep up with what I do.

My thoughts on this are further divided by the fact I know it shows expertise in the subspecialty and helps advance the field further, but at the same time it seems to divide a fragile specialty further.

No negative vibes perceived, PMR4MSK, it is a legitimate question.

I don't have the answer regarding how many subspecialties we should have. I DO believe that if the ABMS subspecialty argument can be made for SCI medicine, Peds rehab, sports medicine, hospice/palliative care, it can and should also be made for BI medicine.

As you point out, subspecialty certification helps advance the field further. From a "political" perspective, BI medicine could use the help, because it presently lacks a scientific/educational forum (such as ASIA in SCI medicine, or AACPDM in peds) where the disparate member of the field can meet and share the latest in scientific and educational information, recruit faculty/fellows, or pull together political clout. Even in the absence of ABMS subspecialty recognition, such forums help develop the field, and can welcome interested physicians and scientists from other specialties/fields who share interest in the field.

Perhaps it is for this very reason that ABPMR has "hesitated" to push BI medicine, as they might justifiably feel that the impetus/leadership for certification should come from the membership of the subspecialty, rather than from the ABPMR.

This is quite the opposite scenario from PASSOR, which developed on its own in response to the needs of its members. Indeed, I believe that it remains to be seen whether the AAPMR, with its broader and more diverse interests, can be relied upon to serve the needs of the (former) PASSOR membership.

 

[Disciple]

I think official recognition of BI as a subspecialty would definitely be worthwhile and justified. The difficulties in making this happen likely involve the need to sponsor an ABMS certification together with the ABPN.

If the will is there, this is something that can be pushed through the CNS Rehabilitation Council, with recommendations passed on to the ABPMR, who in turn could be in contact with representatives of the ABPN.
Until then, “Academy Approved” fellowships in BI would at the very least establish a defined knowledge base to be expected of Physiatric BI specialists, not unimportant with the push towards evidence based treatment guidelines in most specialties, quality assurance from providers, etc.

I can see one point of debate already. Should the sub-specialty be BI (broad) or TBI (narrow)?

Regarding the point of discussion on number of sub-specialties. Physiatry needs to proceed cautiously here, considering both sides of the issue. We have been able to remain relevant by the ease with which we are able to “reinvent” ourselves.

We have a fairly ambiguous central theme “functional restoration”, which allows us to adopt skills from other specialties in the name of our common goal. As such, the burden of proof lies on our shoulders to demonstrate expertise in common skill-sets, equal to those from other more mainstream specialties. For us to remain competitive, we must continue to emphasize learning new skills and raising our level of expertise. This is of particular importance in geographic regions saturated with physician specialists.
The difficulties in achieving this goal lie in establishing this expertise without driving ourselves further and further apart until each niche Physiatrist has more in common with similar sub-specialists from other base specialties than he/she does with Physiatry. If that happens, Physiatry no longer exists and we’re pretty much in the same place we were 20 years ago. This is already happening to a certain degree with Interventional Physiatrists and Physiatric “pain” specialists.

The way I see it, the 2 methods of establishing a greater level of expertise are to either bulk up our residency training standards to equal current sub-specialty level training, or to support the movement toward increasing sub-specialty certification and the necessary additional years of training. In improving base residency training, we know there are limits as to how fast residency programs can evolve and the difficulties in recruiting faculty with appropriate expertise. This was an issue that was brought up at the Sports SIG meeting (we cannot push Ultrasound training requirements onto residency programs at this time as there are simply not enough Physiatrists with the appropriate expertise involved in academics). This is without considering the time constraints of 36 months of PM&R residency training. On the other hand, if we continually add sub-specialty after sub-specialty, when will PM&R become fragmented beyond repair? Paring down from 30 SIGs to 5 councils seems to be a start (however much I disagree with how sub-specialites were grouped/labeled).

In my opinion, the best model is one that is fluid/flexible, allowing for the use of multiple viable pathways. Make use of the resources of progressive individual residency programs that may excel in certain areas, while continuing to make use of our top fellowship programs. Regardless of the pathway taken, hold all Physiatrists in a particular niche to the same standards, and clearly define (to the public, insurers and other physicians) what those standards are.

With a little bit of compromise, we can raise our standards in educating our trainees, thereby raising our standing in the medical community while maintaining the allegiance of our young Physiatrists.

 

[PMR 4 MSK]

Regarding the point of discussion on number of sub-specialties. Physiatry needs to proceed cautiously here, considering both sides of the issue. We have been able to remain relevant by the ease with which we are able to “reinvent” ourselves.

Interestingly, ortho does not seem to suffer as much from this fragmentation. We have 12 orthopods in our practice, and all but 2 (the oldest ones) are fellowship trained and have very narrowly restricted their practice - 3 do trauma, 3 do Upper extremity, 2 do sports medicine and mainly knees and shoulders, 2 do hip and knee replacements. Both of the older ones have stopped doing surgery and just do IMEs and work-up for the surgical cases for the other guys. Our 2 non-fellowship-trained docs are mainly retired now.

There are so many fellowships you can do in ortho now, that the general orthopod seems to be an endangered species. We might go down that road, too.

The difficulties in achieving this goal lie in establishing this expertise without driving ourselves further and further apart until each niche Physiatrist has more in common with similar sub-specialists from other base specialties than he/she does with Physiatry. If that happens, Physiatry no longer exists and we’re pretty much in the same place we were 20 years ago. This is already happening to a certain degree with Interventional Physiatrists and Physiatric “pain” specialists.

Perhaps with the new councils, they can bring these docs back in to PM&R, instead of driving them away as AAPM&R has been doing for the past decade.

...we know there are limits as to how fast residency programs can evolve...

Or in many cases, "won't" evolve.

 

[Disciple]

Interestingly, ortho does not seem to suffer as much from this fragmentation. We have 12 orthopods in our practice, and all but 2 (the oldest ones) are fellowship trained and have very narrowly restricted their practice - 3 do trauma, 3 do Upper extremity, 2 do sports medicine and mainly knees and shoulders, 2 do hip and knee replacements. Both of the older ones have stopped doing surgery and just do IMEs and work-up for the surgical cases for the other guys. Our 2 non-fellowship-trained docs are mainly retired now.

There are so many fellowships you can do in ortho now, that the general orthopod seems to be an endangered species. We might go down that road, too.

From this example, sub-specialization is not necessarily bad for a specialty. However, whether a surgeon belongs to NASS or AOSSM, they still have "bone" and "joint" in common.

Physiatry is so hard to define that 2 sub-specialists on opposite ends of the spectrum can basically have nothing in common except "functional restoration".

 

[Disciple]

MSK was split from Pain to make sure a MSK/Pain council did not overpower all other councils. Also, the academy thought there was enough of a difference between the MSK/Interventional Spine/Sports practicioners and the Chronic Pain/Functional Restoration practicioners to make a split.

Council Enrollment

As of today, Council enrollment totals 1471 Members; approximately 70% are Fellow Members.


Breakdown of Council Enrollment:


CNS: 454

Med Rehab: 352

MSK: 900

Pain: 824

Peds: 157



Special Note: This number does not correspond with the total number of members who have enrolled in Councils as many members have joined multiple Councils.

I think this is what some people were afraid of:

(900+824)/2687=64%


It would be like our democratically controlled congress.