Pediatric physiatry in 2000: A survey of practitioners and training programs☆☆☆

Article Outline

• Abstract
• Methods
• Results
  • Degrees and AAPM&R affiliation
  • Practice sites
  • Practice activity
  • Geographic distribution
  • Training
  • Involvement in academic training programs
  • Research
  • Professional affiliations
  • Preferred means of contact
• Discussion
  • Design limitations
  • Training and availability of training programs
  • Impacts on patients and PRM physiatrists
• Conclusions
• References
• Copyright

Abstract 

Sneed RC, May WL, Stencel C, Paul SM. Pediatric physiatry in 2000: a survey of practitioners and training programs. Arch Phys Med Rehabil 2002;83:416-22. Objectives: To assess the current status and future prospects of the field of pediatric rehabilitation medicine (PRM) physiatry by detailing the demographics, training, research interests, and other characteristics of physicians currently practicing in that field and to determine the availability of training programs in PRM. Design: A printed survey of members of the American Academy of Physical Medicine and Rehabilitation Pediatric Rehabilitation Special Interest Group (PRSIG) and a separate questionnaire directed to departments of physical medicine and rehabilitation (PM&R) concerning their PRM training programs. Setting: Not applicable. Participants: PRSIG members and PM&R training programs listed by the American Board of Physical Medicine and Rehabilitation. Intervention: Between July 1998 and April 2000, a survey was sent to PRSIG members, with follow-up mailings to nonresponding members. Between April and July 2000, a survey on PRM training practices was sent to 82 PM&R departments with fax and telephone follow-up to nonresponders and to those departments that had discontinued their training program. Main Outcome Measures: Instrument measures of physicians practicing PRM, including demographics, geographic distribution, practice sites, training, academic participation, special interests, and research interests along with willingness to participate in collaborative research, association in other organizations, and communication preferences. Data on training requirements as well as availability of PRM fellowships and combined pediatric and PM&R residencies indicate that the number and scope of these training opportunities are declining. Results: There is little uniformity in the amount of exposure to pediatric rehabilitation required by PM&R residency training programs. There are discrepancies in the reported numbers of PRM fellowships and/or combined pediatric and PRM training programs. Projecting the number of physicians who will be practicing in this subspecialty in the future is difficult because there are no reliable data about the number of graduates or trainees in the field. Conclusions: The rehabilitation needs of children are met by physiatrists with specialized pediatric training. Our survey provided a demographic overview of the PRSIG membership. Given the decline in PRM training programs, it is imperative that the remaining programs be strengthened through communication and organization among physiatrists who practice PRM. We believe that a national database and an interactive Web site are feasible means with which to facilitate this goal. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Keywords:  Disabled children, Education, medical, graduate, Physical medicine, Physician's practice patterns, Rehabilitation

It has long been a maxim in the field of pediatrics that “children are not small adults” and thus require health care targeted specifically to them. This is true for all children, including those with disabilities such as cerebral palsy (CP), traumatic brain injury, and muscular dystrophy, and this fact has been recognized by experts in pediatric rehabilitation.¹ The Commission on Accreditation of Rehabilitation Facilities (CARF) also has recognized the uniqueness of pediatric needs and has set specific standards for pediatric, family-centered rehabilitation programs.²

However, the uniqueness of children's medical needs has not always been emphasized throughout the entire medical community. The American Academy of Pediatrics (AAP) was established in 1930 to promote the special health care needs of children, partially in response to the opposition of more adult-orientated physicians and institutions, such as the American Medical Association (AMA), and to the formation of a children's bureau for grants for maternal and child health through the Sheppard-Towner Act.³, ⁴, ⁵, ⁶ The development of pediatric rehabilitation medicine (PRM) has mirrored the establishment of the AAP. Although the specialty of physical medicine and rehabilitation (PM&R) has been recognized by the American Board of Medical Specialties (ABMS) since 1947,⁷ discussions of criteria for a PM&R residency did not include pediatrics until 1967.⁸, ⁹

With the inclusion of pediatrics into PM&R training, PRM became a recognized subspecialty for physicians specially trained to manage the particular health care needs and issues of children with special needs. Until now, little information and data about the demographics of physiatrists who practice PRM have been available, other than reports regarding PRM training programs.¹⁰, ¹¹, ¹² In October 1996, the Pediatric Rehabilitation Special Interest Group (PRSIG) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) proposed to survey its members to develop a computerized database of member information. The survey began in July 1998 and continued until April 2000. Data from the survey are reported here, which we believe present a nearly complete census of current and recent PRSIG membership. A concurrent survey of 82 PM&R departments was undertaken to assess the availability of training programs for current and future PRM specialists.

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Methods 

A list of PRSIG members was obtained from AAPM&R, as were the 1998, 1999, and 2000 editions of the AAPM&R Membership Directory. Every listed member was sent a survey form between July 1998 and April 2000. Nonresponders were periodically recontacted by mail throughout this period. A total of 166 members responded (25 did not), giving an 86.9% response rate. The final number of respondents exceeds the current number of PRSIG members, reflecting the fact that previous members have not maintained their membership, and new members have joined the PRSIG. Respondents who stated that they had been misidentified as PRSIG members were not counted. Survey results solely reflect the respondents' self-described status as qualified PRSIG members. Other than checking listings in the AAPM&R directories and PRSIG membership lists, no cross-validation was performed.

A separate survey was mailed in April 2000 to the 82 PM&R residency programs identified in March 2000 by the American Board of Physical Medicine and Rehabilitation (ABPMR) to determine whether the programs (1) require a training in PRM, (2) offer a PRM fellowship, and (3) offer a combined pediatric and PM&R (pediatrics/PM&R) residency. We did not determine if the programs could provide numbers of current or past graduates. The response rate was 100%. Results of this survey were then compared with the official listings from the ABPMR and the AAPM&R fellowship database, both as of March 2000.¹³ Discrepancies between the survey results and information provided by the AAPM&R and ABPMR were clarified in July 2000 by direct telephone contact with the PM&R departments in question, again with a 100% response rate. At that time, we asked about the reasons for any program discontinuations. Responses from program directors were taken as opinion and were not formalized.

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Results 

Analyses of the PRSIG membership survey are presented in figure 1 and tables 1 and 2.

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• Fig. 1. 

  Changes in PRM of the PRSIG over the past 50 years and cumulative distribution based on self-reported training type.

Results of the PM&R training program survey are presented in table 3. Only 57% of the programs require 3 months or more of pediatric training during a general PM&R residency, down from the 81% of the programs that required 3 months between 1988 and 1989.¹⁰ Four programs required only 1 month of pediatric exposure, and 4 had no mandates for PRM training.

Table 1: Practice demographics for PRSIG members

Abbreviations: MD, doctor of medicine; DO, doctor of osteopathy.

Table 2: Distribution of PRSIG members among the United States and select territories

Table 3: Required time for pediatric training in general PM&R residencies

In March 2000, the AAPM&R fellowship database and ABPMR listed 21 PM&R departments that offered PRM fellowships and/or combined pediatrics/PM&R training programs. However, in our survey, only 5 of the departments reported having fellowship offerings, and only 6 confirmed having combined pediatrics/PM&R programs. Our survey identified 1 department with a PM&R fellowship that was not included in the AAPM&R list and another that reported a PMR combined pediatrics/PM&R residency program that was not on the ABPMR list. In total, only 6 PRM fellowship programs and 7 combined pediatrics/PM&R residencies were active when this paper was submitted for publication.

Degrees and AAPM&R affiliation 

Doctors of medicine constitute the majority (93.4%) of PRSIG members; doctors of osteopathy make up the rest (6.6%) (table 1). Nearly 70% of the responding PRSIG members indicated that they were AAPM&R fellows, with 13.9% designated as associates, 4.2% as seniors, 3.6% as correspondents, and the remainder falling into other categories.

Practice sites 

Although several respondents indicated that they practiced at multiple sites, the survey asked that they list only their primary practice site (table 1). The largest percentage (31.3%) practiced primarily at general pediatric hospitals. About 17% listed general rehabilitation hospitals, and 13.3% indicated outpatient, non–self-owned, private offices or clinics. Rehabilitation hospitals accepting only pediatric patients accounted for only 9.6% of practice sites.

Practice activity 

The vast majority (92.2%) of the members indicated they were actively practicing (table 1). Only 6% said they had retired. Asked whether they see only children, 28.3% replied affirmatively, and 65.7% indicated that they treat both children and adults. Only 1.2% said they do not see pediatric patients, even though they were PRSIG members. Clearly, most PRSIG members do not limit their practice to pediatrics alone. As a cross-verification, the survey asked participants to indicate whether pediatrics made up 0%, less than 50%, exactly 50%, or greater than 50% of their practices. As expected, the majority (61.5%) reported seeing more children than adults, but for a substantial minority (38.5%), children represented less than half of their patients.

Geographic distribution 

Survey results showed that at least 1 PRSIG member lives in each of 36 states, the District of Columbia, and Puerto Rico (table 2). Seven countries also are represented by PRSIG members. These results do not include the locations of the 25 PRSIG members who did not respond to the survey. Three states—California, Minnesota, and New York—have the highest number of PRM physiatrists, with Illinois, Michigan, Ohio, and Texas having the next highest concentrations. The majority of states (69.2%) have only 3 or fewer pediatric physiatrists.

Training 

Figure 1 shows 2 separate trends, the distribution of training background for each division of years completed at that time and the cumulative numbers and distribution of PRM training backgrounds. Overall, the cumulative training of the members is almost evenly divided between the 4 main types of training—combined pediatrics/PM&R residency (23.5%), individual PM&R and pediatric residencies (27.7%), PM&R residency and PMR fellowship (24.7%), and PM&R residency only (24.1%). However, figure 1 shows that, in the past 5 years, the combined pediatrics/PM&R residency program has become the predominant source of PRM training (54.5%), with PM&R residency coupled with a PRM fellowship a distant second (25.5%). During the past 5 years, only 20% of graduates came from the other 2 more traditional pathways.

Of survey participants, 84.5% reported that they are certified by the ABPMR. Just over 37% reported being pediatric board certified, and 31% said they were certified by both ABPMR and the American Board of Pediatrics. Eighteen percent said they were certified by other boards, with the majority being diplomates of the American Board of Electrodiagnostic Medicine. It should be noted that some of the members surveyed were still in, or had just completed, training programs and were not eligible to take board examinations.

Involvement in academic training programs 

Regarding the impact of PRSIG members on academic programs, 79.5% of the respondents reported that they participated in academic training. General PM&R residencies comprised the majority (59.6%) of training programs with which members interacted. Fewer participated with PRM (38.6%) programs, general pediatric training programs (37.3%), or family practice (9.0%). Others (9.6%) listed programs such as internal medicine, neurology, spine, orthopedics, and surgery. Participants were allowed more than 1 selection.

Research 

We asked respondents about their principal research interests and special clinical practice interests in PRM outside of their primary research. A significant percentage of the respondents (54.8%) were interested or actively involved in PRM research. Brain injury (15.7%) and spasticity (16.3%) were the research areas listed most often; in total, there were 63 categories of other interests, including CP, botulinum toxin, sports and exercise, brachial plexus palsy, outcomes, spinal cord injury (SCI) computers, and technology. Almost 78% of respondents listed 1 or more fields of special clinical practice interest outside of their main research focus. Less than 20% indicated no special clinical interests. The main areas of interest were brain injury (27.7%), spasticity (27.7%), CP (24.7%), SCI (10.8%), and spina bifida (9.6%). Other areas of special interest included neuromuscular, electrodiagnosis, sports and exercise for the disabled, brachial plexus palsy, arthritis, botulinum toxin, musculoskeletal, orthotics, pain management, technologic applications, and other areas (total categories, 66). The majority (77.1%) were interested in collaborative research projects, and 78.3% were willing to share their name in that capacity.

Professional affiliations 

Of the 166 respondents, 60 (36.1%) indicated they were members of other AAPM&R special interest groups, predominantly the Brain Injury and Spinal Cord Injury Special Interest Groups. Seventy-one (42.8%) reported AAP membership, and of those, 20 were members of the Section on Children with Disabilities. Seventy-four (44.6%) were AMA members, and 82 (49.4%) listed memberships in other national organizations. Ninety-five (57.2%) reported membership in the American Academy for Cerebral Palsy and Developmental Medicine. Twenty-five (15.1%) said they are members of the American Congress of Rehabilitation Medicine. Ninety-three (56%) reported being members of state and local PM&R societies, and 42 (25.3%) reported that they were also members of state or local pediatric societies.

Preferred means of contact 

Regarding how they preferred to be contacted, 62% of respondents indicated that they preferred postal mail; only 24.7% listed electronic mail as their primary contact method. Even so, 66.3% did list an e-mail address. Of the remainder, 6.6% preferred to be contacted by fax, 1.8% preferred telephone, and 4.8% gave no response. The majority (69.3%) preferred to be contacted at their practice locations, whereas 27.1% preferred to be contacted at home and 3.6% gave no response.

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Discussion 

Although the diversity of disorders that require physical and/or cognitive rehabilitation makes it difficult to obtain exact figures,¹⁴ studies indicate that pediatric patients with these disorders (eg, CP, muscular dystrophy, spina bifida) have a significant impact on the health care community.¹⁵ Although many pediatric patients currently are served by PRM physiatrists, more could potentially benefit from the expert coordination of care and rehabilitation management provided by these specialists. Thus, information about the training and practice of PRM physiatrists would be extremely useful.

Design limitations 

There appear to be 4 different training pathways for individuals who want to practice pediatric rehabilitation (fig 1). Given the lack of standardization among these pathways, we decided that the most feasible way to identify persons who practice pediatric rehabilitation was through the PRSIG, while recognizing its limitations. As with all of AAPM&R's special interest groups, membership in PRSIG “does not involve or connote academic certification or approval to practice in that area of special interest.”¹⁶, ¹⁷ Also, one must have some affiliation with AAPM&R to be a PRSIG member; although some residents may be members, there may be a lag time—up to 5 years or more after graduation—before these newer physicians actually join the AAPM&R and the PRSIG. Additionally, some physiatrists may have chosen not to affiliate with the AAPM&R and/or PRSIG and thus were not surveyed.

It would be helpful to know the number of graduates and present trainees in the field of pediatric rehabilitation so that projections could be made of the number of physicians in this specialty in the future. Graduate programs might be considered a source of information on all past and current trainees. However, the actual number of existing programs turned out to be far lower than we had anticipated, based on AAPM&R's Website and ABPMR's listings. Several programs have been discontinued. Given this shrinkage of programs in the past 5 to 10 years, obtaining accurate information on all individuals who practice pediatric rehabilitation is somewhat problematic. It would be difficult to go back to all the existing and defunct programs to obtain detailed information regarding graduate rates over the past 5 to 20 years, and we doubt that personnel could be found in some cases who could supply this data. We did ask our survey respondents to report their last year of training, which could help capture with some accuracy the group's membership numbers up to the last decade. However, we believe that the accuracy of these numbers falls off during the last decade, particularly in the past 5 years, because new graduates have not yet taken boards examinations and become AAPM&R and PRSIG members. Thus, we felt that we could not design the survey to determine the numbers for future projections. We are unaware of any other readily available means of identifying all physiatrists who practice PRM, although we are personally aware of some non-PRSIG members who do. Therefore, we believe that the data from our PRSIG survey likely present the most comprehensive overview available to date of PRM physiatry practice in the United States.

To discover the reasons for the decline in training programs, we solicited comments from program directors through follow-up telephone calls to institutions where such programs had once been offered but now are no longer available. These questions and resulting comments were not a part of the original program survey or on the questionnaire forms.

Training and availability of training programs 

As noted earlier, pediatrics was not considered in PM&R residency requirements until 1967.⁹ The Accreditation Council for Graduate Medical Education (ACGME) is responsible for certifying residency programs in PM&R.¹⁸ As confirmed by personal communication with the ACGME PM&R in January 2001, it has never mandated in the program requirements for PM&R that pediatrics be part of fundamental clinical skills training, although it recognizes pediatrics as an acceptable choice.¹⁸ Nor has ACGME stipulated a specific amount of time to be spent with pediatric patients.¹⁸ The ACGME guidelines that have been in force since January 1996 state that the first year of fundamental clinical skills development may include (but does not require) pediatrics among several specialty choices. The only explicit mention of pediatrics training in the ACGME's Educational Program occurs in section V, Clinical Components, which states that each resident should display measurable competency in several areas, including “item k: the rehabilitation of children.”¹⁸ Thus, time frames and requirements for PRM training appear to be largely left to the discretion of individual programs and resident interest, with little uniformity in the amount of pediatric exposure required of graduates.

The survey of the 82 PM&R residency programs (table 3) found that only 57% required 3 months or more of pediatric training during a general PM&R residency, a decline from the 81% of the programs requiring 3 months between 1988 and 1989.¹⁰ Four programs required only 1 month of exposure, and 4 had no requirements for pediatric training.

Regarding PRM fellowships (table 3), Gans and Nagy¹¹ reported 13 fellowship programs in 1989 and Hurvitz and Nelson¹⁰ cited 13 existing and 6 planned by 1989. Regarding combined pediatrics/PM&R programs (table 3), DeLisa¹² reported 5 such residencies in 1988, Hurvitz and Nelson¹⁰ cited 19 in 1989, and DeLisa¹² reported 21 potential programs, with 16 active in 1997. The current cumulative counts (fig 1) of total PRSIG membership reflects not only the most recent graduates but also all graduates who remain or were former members of PRSIG during the survey period, including 6% who have retired. Figure 1 shows that combined pediatrics/PM&R residencies since 1995 have been the main resource for PRM training (54.5%), with fellowship programs next (25.5%). The survey of current training programs did not ask about past or current numbers of graduates from PRM programs, but only about whether such programs currently existed. Therefore, although the cumulative numbers of PRSIG members who practice at least some PRM have increased over the past 50 years, our current data does not help define specific future changes in the numbers of PRM physiatrists. The decrease in PRM training programs, both combined residencies and fellowships, could have significant implications for the availability of PMR physiatrists in the future as older PRM physiatrists retire, resulting in, at minimum, a leveling off or a decline in the numbers of practicing PRM physiatrists. Heightening this concern is that combined residencies and PRM fellowships, which were the training sources for approximately 80% of PRM physiatrists since 1995 (fig 1), appear to be declining.

The discrepancies between our survey results and the larger number of pediatric training programs listed in the AAPM&R fellowship database and ABPMR reports were discovered through our follow-up queries to the discontinued programs. Our findings reflect the ongoing fluctuation of PM&R department staffs, programs, and funding, as well as delays in reporting to and encoding by national organizations. It appears that much of the institutional information is outdated, and that many PM&R departments have discontinued their pediatric fellowships and/or combined residency programs in the last 1 to 3 years. The most common reasons program directors gave for the closures included capitation of funding and/or lack of interest and applicants. The prospect of lower remuneration for PRM care, as compared with other physiatry fields, was cited as a factor inhibiting resident interest. Our survey suggests that only a small percentage of current PRSIG members either want or are able to limit their practice to PRM (table 1). A few PRM programs remain “mothballed” for potential reactivation if interested applicants appear, but they are not currently funded.

Impacts on patients and PRM physiatrists 

In light of these findings, are graduates of residencies in general PM&R programs adequately trained to manage the needs of children? One proposal suggests that general pediatricians provide “medical management” by consulting in the rehabilitation unit. However, this solution does not address the need to apply PM&R principles adequately to pediatric special conditions. It has been documented that pediatric residency training programs appear not to provide training adequate to meet the physical rehabilitation needs of children.¹⁹, ²⁰ General pediatricians cannot be expected to manage special needs cases if they are not trained in these areas. Additionally, the Health Care Financing Administration compliance regulations may limit ongoing joint management of a patient by 2 or more physicians; only 1 may assume the primary role, and only limited time frames and specific problems-focused billing by consultants are allowable.

Most states (69.2%) have 0 to 3 physiatrists (table 2). It seems unlikely that these small numbers could provide adequate coverage to their respective states' entire population of children with special needs. If our survey's noted decline of PRM training programs is correct, then even greater concern arises for future national coverage as older PRM physiatrists retire.

At the same time that PRM training options are declining, the number of other medical professionals interested in providing rehabilitation services to patients of all ages continues to increase. For example, neurologists increasingly provide neurorehabilitation, cardiologists and internists offer cardiopulmonary rehabilitation, and orthopedic specialists offer sports medicine rehabilitation. In a 1999 newsletter; the AAP Section on Children with Disabilities informed its membership that 2 new subspecialty boards—neurodevelopmental disabilities and developmental and behavioral pediatrics—have been approved by the ABMS.²¹ The ABPMR was not mentioned in this newsletter or in subsequent issues; nor did AAP provide any indication that it is supportive of this third board. This is so despite the fact that, as our survey determined, at least 20 members of the PRSIG are members of the AAP Section on Children with Disabilities and 71 PRSIG members are affiliated with AAP. Also, as we have previously reported,²⁰ AAPM&R in 1997 voiced concerns about a proposal for a subspecialty in neurodevelopmental disabilities, questioning whether it adequately addressed rehabilitation needs, particularly in regard to PM&R issues.

CARF guidelines for pediatric family-centered rehabilitation programs have somewhat vague qualification requirements for physicians involved with these programs.² Although CARF states that a pediatric physiatrist is needed to provide “input into the overall program direction related to medical issues,” it also recognizes that this input may come from “a pediatrician with a completed fellowship in behavior, development or rehabilitation; a pediatrician with two years' experience in pediatric rehabilitation/habilitation”; or “a physician with comparable training and experience.”² The guidelines do not specify what constitutes comparable training and experience. Furthermore, CARF states that the physician may provide this service as a “medical director,” but it may be sufficient that a “chair or member of a professional advisory committee” or “a consultant with a formal arrangement” provide the input.² Clearly, credentials qualifying a person to provide medical input to such a program can be quite broad. Yet, it has been documented that training in management of therapy services and durable medical equipment is lacking in training programs for general pediatricians who often provide the initial care of these children or and must recognize the need to refer them to an appropriate specialist.¹⁹, ²⁰ CARF does not require day-to-day management, ordering, or supervision by a physician trained specifically in PRM.

Greater pediatric training and/or standards for and credentialing in postgraduate practice in handling PRM issues should be desired goals. In part, the establishment of the new ABPMR subspecialty of PRM may already be addressing these goals. As of March 1999, the ABMS granted ABPMR the right to offer certification in PRM; the first examinations are tentatively set for October 2003.²² At the time this paper was submitted, ACGME had yet to certify this subspecialty.

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Conclusions 

Just as other divisions of the health care field have recognized that “children are not small adults” but have unique needs that require specific pediatric-based training, so, too, should physiatry continue to enhance requirements for PRM expertise and training of physicians who treat children and adolescents for physical and/or cognitive disabilities. Our survey of PRSIG members shows a diversity of training backgrounds, practice sites, and activities; memberships in other health care professional organizations; and special clinical and research interests, plus a gratifying willingness to engage in collaborative studies. Our survey of PRM programs, however, suggests a significant shrinkage in availability of programs that produce PRM physiatrists. This could impact the developing ABPMR PRM boards. AAPM&R's PRSIG appears to be the most organized resource in physiatry to act as an advocate for pediatric PM&R issues. Therefore, AAPM&R should further investigate options to fortify pediatric elements in physiatry training and PRM recognition. Enhanced communication among its diverse members may be 1 option to promote the expertise of PRM physiatry among other health care providers and consumers. In this electronic and Internet age, a central Web site and interactive database may be useful tools with which to facilitate enhanced communication and interaction. The declining number of and interest in training programs for PRM physiatry and the concurrent increasing numbers of other health care professionals involved in PRM, including its physical medicine aspects, make it even more imperative to achieve these goals.

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