History of Physiatry Past, Present, Future

1. History of PhysiatryPast, Present, Future Andrew L Sherman, MD, MS Associate Professor Department of Rehabilitation Medicine University of Miami Miller School of Medicine

2. Disclosure statement No conflicts to declare relevant to this talk

3. History of Physiatry • Since the beginning of time, people have used physical means for treatment of illness and injury. • Water, heat, cold, massage, light, exercise and electricity • Written accounts of physical techniques for healing can be traced as far back as the writings of Hippocrates in 400 B.C

4. AMSA statement “For medical students with little exposure to the field, physiatry is just a game-winning Scrabble word. In fact, it’s one of the fastest growing and diverse medical specialties of the 21st century”

5. AMSA statement “One aspect of the specialty that practitioners love is its variety. Today, physiatrists treat an extensive range of conditions, including arthritis, stroke, neurological disorders, musculoskeletal conditions, traumatic injuries—including brain and spinal cord injuries—chronic pain, work and sports injuries, and chronic diseases.”

6. AMSA statement “Those having some familiarity with the specialty may write it off as simply advanced physical therapy. In fact, we are the team captains, coordinating occupational therapists, physical therapists, social workers, psychologists and everyone else involved in the care of a patient in rehab. When a patient has problems urinating and his therapist doesn’t know what to do, we are the go-to guys.”

7. History of Physiatry • During and after World War I, empirical trials indicated that various physical methods were useful to augment medical care and convalescence of patients. • Physicians began practicing "physiotherapy" in "reconstruction hospitals" to rehabilitate injured and disabled soldiers.

8. History of Physiatry • Beginning in the 1920's, medical organizations such as the AMA Council on Physical Therapy and the American Society of Physical Therapy Physicians were formed. • Formal education for Physiatry had its beginning in 1926 when, after service in the U.S. Army during World War I, Dr. John Stanley Coulter joined the faculty of Northwestern University Medical School as the first full-time academic physician in physical medicine

9. History of Physiatry – 1930’s • Frank Krusen, MD, established the Physical Medicine Program at the Mayo Clinic in 1936 and initiated the first three-year residency in Physical Medicine • He is recognized as the "Father of Physical Medicine.” • Krusen and Coulter established the American Academy of PM&R in 1938

10. History of Physiatry – 1940’s • Krusen wrote the first widely used textbook on Physical Medicine in 1941. He is recognized as the "Father of Physical Medicine." • In 1946, the AMA Council on Physical Medicine voted to sponsor the term "physiatrist" (fizz-ee-at'-trist) and physiatry (fizz-ee-at'-tree) with the accent on the third syllable. This is how the pronunciation appears in most American dictionaries.

11. History of Physiatry – 1940’s • Howard Rusk, MD: • Set up a controlled experiment in one barracks in which active rehabilitation was carried out while a control barracks continued the passive program of convalescence. • The dramatic demonstration of the more rapid recovery of strength and endurance and the much more rapid return to active duty due to the benefits of planned aggressive rehabilitation were so remarkable that the Army Air Corps extended the program throughout the military services.

12. 1940’s • After the war, Rusk left his medical practice in Missouri and went to New York's Bellevue Hospital where he began his 30-year campaign to train physicians and establish rehabilitation programs to treat the whole patient

13. History of Physiatry – 1940’s • By 1946, medical residencies or fellowships in PM&R had been established at 25 hospitals as a result of funding from the Baruch Committee. • In January 1947, the Advisory Board of Medical Specialties (now the American Board of Medical Specialties) formally recognized the American Board of Physical Medicine. Two years later, at the urging of Dr. Rusk, the name was changed to include "Rehabilitation." • 85 positions for residents or fellows in Physical Medicine and Rehabilitation

14. Certification Occurred in 1947 At that time there were 91 physiatrists practicing in the USA by 1975, there were 1,164. In only ten years, that number doubled, reaching 2,377 in 1985. It more than doubled again in the next decade. In 1995, there were nearly 5,000 board-certified physiatrists. Now there are nearly 10,000

15. History of Physiatry – 1950’s • WWII over – Korean conflict looming, cold war occuring • Polio epidemic – 58,000 cases • Created an increased demand for physicians trained in a comprehensive approach to rehabilitation, including the physical, mental, emotional, vocational and social aspects.

16. History of Physiatry – 1950’s Mary Switzer, director of the Office of Vocational Rehabilitation (OVR) brought about the economic opportunity for the great expansion of PM&R. She was totally committed to the improvement of the quality of life for people with disabilities. She became convinced PM&R directed by physiatrists could provide the greatest benefits for people with disabilities.

17. History of Physiatry – 1950’s Her effectiveness as an administrator and advocate for the disabled before Congress resulted in greatly increased budgets not only to provide rehabilitation services, but also to support physiatric training programs, physiatric fellowships, and support for research. During her administration, the concept of regional rehabilitation research and training centers was adopted and funded by Congress.

18. History of Physiatry – 1950’s • The 1950's brought an increase in the numbers of rehabilitation professionals • More cohesive union between the fields of Physical Medicine, Rehabilitation Medicine, and Electromyography. (EMG) was desired and obtained. • Electromyography (EMG) was introduced into Physiatry as a profoundly important method for the evaluation of problems of the neuromuscular system, which constitutes a major part of the work of the physiatrist.

19. History of Physiatry – 1960’s • Clinical and educational opportunities multiplied • Interest in physiatric research multiplied • The Association of Academic Physiatrists (AAP) was formed in 1967 by a small group of dedicated physiatric educators with Ernest W. Johnson, MD, considered the "founding father". • The AAP mission is concerned with issues such as support for academic departments, improving the quality of teaching programs and encouraging the development of physiatric research

20. History of Physiatry – 1960’s -Florida Organizational meeting of the group that would become the Florida Society of Physical Medicine and Rehabilitation in Miami. Seven physiatrists attended: Drs. Pedro Arroyo, Norman Borkin, George Cunningham (Palm Beach), William Fleming, Arthur Pasach ( Tampa), Stansky (or Nixon) (Bay Pines VA) and Bruce Sutton (Coral Gables VA).

21. History of Physiatry – 1960’s - Florida Dr. Pasach remembers that Dr. Fleming put together the first set of By-Laws, and that they met around a poker table and adjourned after the meeting for BBQ ribs and corn at Shorty’s. Dr. Pasach, who had come to Tampa in 1958, was elected the first President, Dr Cunningham the Secretary. Meetings were very collegial, consisting of a scientific case reports and discussion of mutual problems.

22. History of Physiatry – 1960’s - Florida Dr Pedro Arroyo was elected President. He had arrived in Miami in 1959 as the Medical Director of the Rehabilitation Center for Crippled Children and Adults ( Easter Seal) and found the local reputation of PMR to be very poor, as rehabilitation was seen to be the province of Orthopedics. Serving as consultant to the VA and the School of Medicine, he continued to pioneer the specialty, writing for the Journal of the Florida Medical Association and securing a grant from Vocational Rehabilitation for a yearly course in Principles of Rehabilitation for non-physiatrists.

23. History of Physiatry – 1970’s • In 1974, the Commission on Rehabilitation Medicine published a bulletin: Physical Medicine, Need, Supply and Demand, 1972-1987 • Severe shortage of physiatrists predicted • Joel Delisa, MD – Archives of PMR, Kessler • Expansion of residency positions begins

24. History of Physiatry – 1970’s - Florida New Constitution and By-Laws adopted. The qualifications for Active membership now specified board certification. Associate membership granted to board-eligible candidates and Affiliate membership to residents in training.

25. History of Physiatry – 1980’s • In the 1980's, there is recognition by the American public that medical rehabilitation decreased dependency and increased the quality of life for handicapped persons. • PPS was invented – Rehabilitation beds exempt • Resulted in the development of many community rehabilitation centers and created a demand for many more physiatrists to direct these medical programs. • Indeed a shortage of physiatrists materialized • Increased residency slots, increased physiatrists

26. History of Physiatry – 1980’s • Studies by the Saul Brothers and Weber indicated that non-operative care of lower back problems and herniated discs should be largely non-surgical • Use of rehabilitation programs, medications, and spinal injections opened new opportunities for physiatrists interested in sports and musculoskeletal medicine.

27. History of Physiatry – 1980’s - Florida During Dr. Pasach¹s term as President, the Neurologic Injury Compensation Association (NICA) was enacted, and a significant focus of Society attention was the push toward tort reform. 1988: Officers installed: President Dr Dorothea Glass, VP Dr David Lipkin, Secretary-Treasurer Dr Enrique Monasterio May, annual meeting Safety Harbor 15 members attended. Society has 37 members. Dues increased to $50 (From 25$).

28. History of Physiatry – 1990’s • In 1994, the American Board of PM&R reported 1313 residency positions were offered and 1277 (97 percent) of those positions were filled – 85% by American graduates • Total number of Board Certified Physiatrists grew to 4642 (1994), with 2561 of those certified between 1984-94 • The average age of a physiatrist is now under 40 and still decreasing

29. 1996 workforce study • At the 1994-95 level of residency capacity, the supply of physiatrists would nearly double in 20 years. The specialty would be challenged to absorb this growth in supply as market conditions changed in the managed care environment. • The South appears to be the region with greatest growth potential for physiatrists, while the Northeast and states adjoining the Great Lakes are areas that are more likely to have excess numbers of physiatrists.

30. P F Hogan, A Dobson, B Haynie, J A DeLisa, B Gans, M Grabois, M M LaBan, J L Melvin, N E WalshPhysical medicine and rehabilitation workforce study: the supply of and demand for physiatristsArchives of physical medicine and rehabilitation. 02/1996; 77(1):95-9.

31. History of Physiatry – 1990’s Seizmic shift in PM&R The MSK area is growing – a few becoming highly procedural – to some harsh criticism from peers. Inpatient programs on west coast shrinking - Feeling inpatient rehab = neurorehab Subacute programs growing – (grwothe temporarily slowed by reduction in SAR reimbursement in 1997)

32. History of Physiatry – 1990’s - Florida October incorporated as 501 (c) (6) non-profit corporation (business league professional association)  Concerns of the Society include proposed P.T. practice act which permitted treatment without physician prescription  Of 147 physiatrists in Florida, 92 are FSPMR members  Society agrees to contract with Executive Director (Lorry Davis)   Education Committee reports 1) One month rotation at Mayo Clinic Jacksonville (Thorsteinsson) 2) Site visit for Miami program scheduled. 9Ultimately not funded due to hurricane Andrew)

33. History of Physiatry – 1990’s - Florida Other problem – Medicare not paying! February FSPMR invited to participate in CPAC ( Carrier Physician Advisory Council) for establishing Medicare B benefits. (Drs Villalobos, Vaughen) As AAPMR Liaison Councilor Dr Mitch Freed spearheads FSPMR member assignments to discuss basic benefit packages with members of Florida House-Senate Healthcare Committee

34. History of Physiatry – 1990’s - Florida May 31 Meeting Bal Harbour with FMA. 121 members. Program Practicing PMR in the Subacute Setting including definition, accreditation, contracting and use of physician-extenders Reports: Exec. Dir. Davis presented FSPMR¹s WC Gatekeeper initiative to the Council of State PMR Presidents.

35. History of Physiatry – 1990’s - Florida FSPMR votes to form PLAC (Physiatric Legislative Action Committee) to establish lobbying activity through a Trust. Drs. Freed, Haddock, Imfeld, Hunter explore locating lobbyist (Staver Group) contracted at $ 26,500/yr. Membership assessment is initiated. Only physiatrists to review cases involving PMR practice

36. History of Physiatry – 2000’s • The landscape changed • Explosive growth has continued – most so in the areas of pain medicine, sports medicine, disability medicine, medical legal work. • “Interventional physiatrist” • Inpatient rehab is under fire from CMS 13

37. CMS 13 • Medicare states that 75% of an inpatient rehab unit must be made up of patients with one of 13 diagnosis • Overall goal from Medicare is to reduce inpatient rehabilitation costs – divert patients with primarily medical and simple joint replacement diagnoses to less intensive care

38. CMS 13 • For the individual physiatrist, this will result in increased requirements to justify the need for intensive inpatient rehabilitation services to outside surveyors • Increased education of non-rehab physicians and allied health personnel • Ultimately increased utilization of SNF’s

39. Pain Management • 4th vital sign • Demand increasing • Many specialties participating • New requirements from fellowships mandate multidisciplinary training • Interventional option • Subspecialty boards

40. Research • REHABILITATION MEDICINE SUMMIT -Building Research Capacity – 2005 • http://www.foundationforpmr.org/summit/bibliography.html • Rehabilitation Medicine Scientist Training Program (RMSTP) • http://www.physiatry.org/research/k12info.html • Research Enrichment Program for Physiatrists. Missouri Arthritis Rehabilitation Research and Training Center • http://www.muhealth.org/~rep/ • Department of Veterans Affairs Rehabilitation Research & Development Service • http://www1.va.gov/resdev/ • http://www1.va.gov/resdev/about/rehab.cfm

41. History of Physiatry – 2000’s • Despite the changes, the need for a physician to provide holistic medical care to patients with disabilities should continue and increase. • Advances in technology should fuel further demand for physiatrist’s services. • Continuing research will lead to advances that will ultimately benefit our patients and help physiatrists provide state of the art care.

42. History of Physiatry – 2000’s 2005 – Start of first residency at University of Central FL/Tampa VAHS – Jeff Scott, MD program director 2005 – Start of SCI fellowships at TAMPA VA and JMH/Miami VA/Univ of Miami 2006 Start of PMR residency at JMH/University of Miami Miller School of Medicine – Andrew Sherman, MD Program director Now up to 18 residents – 19 graduates so far.

43. JMH Rehabilitation Residency Mission : To provide a each resident with the opportunity to achieve competence in ALL aspects of PM&R by facilitating a positive educational and work environment that allows for an open exchange of ideas, so that upon graduation, each resident can function independently as an excellent medical provider in any setting – academic or private practice - with the highest degree of confidence and proficiency.

44. Results • 19 graduates • 2 took jobs as academic attending – inpatient/outpatient/EMG • 3 went directly onto private practice • 1 impatient/consultation • 1 Joined a group - inpatient/outpatient/EMG • 1 in solo practice - outpatient/EMG/accupuncture

45. Results • 14 went for fellowships (about 2/3) • 2 SCI • 12 MSK/Sports/Spine/Pain • 1 SCI fellow went then for pain fellowship • 13/19 – 70%

46. New Decade 2011 and beyond • Pendulum swinging back for inpatient rehab – improvements lead to opportunities. • Outpatient landscape changing – • Challenges from insurance limits on procedures • New opportunities from • Biologics • MSK ultrasound • Stimulation • Alternative treatments

47. Questions?