Is PM&R Teetering on the Precipice of a Dark Age?

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Abstract 

Gans BM. Is PM&R teetering on the precipice of a dark age?

Physical medicine and rehabilitation has had a fascinating history of creation, growth, evolution, maturation, and challenge in the 80 or so years it has existed. Today, we are on the brink of the most serious challenges ever to face the specialty. In this address, I review briefly the history of the field, show evidence of our successes, identify the many overwhelming challenges we now face, and forecast a potential doom for our field. In the end, I offer specific strategies and tactics that the field should follow to guide us to a bright and reinvigorated future.

Key Words:  Physical medicine , Rehabilitation

OUR FOUNDING FATHERS, in the 1920s and 1930s, built on new technologies and used physical agents to create our field of physical medicine and rehabilitation (PM&R). In the 1940s, the field became more formalized with organizations working to achieve recognition from organized medicine; this resulted in the establishment of the American Board of Physical Medicine and Rehabilitation in 1947. During the 1950s and 60s, the field grew and became a small but established specialty. During the 1970s, academic programs developed and flourished. In the 1980s, the number of hospitals that offered inpatient rehabilitation care exploded as Medicare reimbursement for acute care hospitals transitioned to the diagnosis-related groups system, and rehabilitation hospitals continued to be reimbursed on a cost basis (up to a target ceiling). The interests of incoming physiatry residents shifted substantially away from inpatient rehabilitation in the 1990s, and outpatient musculoskeletal medicine became a more dominant influence on the specialty as a whole. In the late 1990s and early 2000s, payers started assaulting reimbursement for hospital and physician care, emphasizing utilization constraints, payment avoidance strategies, and enhanced efforts to effect substitution with less-expensive services.

Over the past few years, it has become apparent to me that PM&R and medical rehabilitation are viewed by policymakers and insurers as “the problem” rather than “the solution.” We see ourselves as unique saviors for patients with catastrophic injuries and illnesses or patients with challenging musculoskeletal disorders, but policymakers and insurers see us as self-serving, profit-motivated providers promoting overutilization and unnecessary service consumption!

As a field, we have fallen from grace. Yet, we have had striking successes that should be honored.

But, it seems that no good deed goes unpunished. The marvelous advances we have made in providing care to outpatients and inpatients have had unanticipated consequences.

In addition, government, big business, and insurers are struggling to contain the continuing expansion of health care costs.

Nipping at the heels of our field are many threats, including the following:

So, despite our marvelous history and our glorious successes, the challenges we now face from within and without the field are putting us at high risk for a dark future. It is possible that without deliberate and aggressive intervention, our field could face the following fate:

And so, the field fades from existence, and patients lose access to the caring physicians we are who see disease and impairment in a functional and societal context.

But, we can avoid this impending doom, and transform this potential Dark Age into a new Golden Era for PM&R.

To do so, we must hold true to our values and truths. We must be prepared as individuals and organizations to speak out loudly and boldly for the things we believe are right. We must fight to preserve respect for our specialty and for our patients. We must expose our plight to the public and make it their concern for our society, not just our concern for our livelihoods. And, we must embrace the responsibility for self-monitoring our field and be accountable to the public for our practices through tools such as maintenance of certification and public disclosure of outcomes.

Because PM&R is a small field, we must ally ourselves with other groups that share our values. They will include the following:

We should grow Academy membership as well, not only by capturing and retaining all physiatrists as members but also by expanding our membership categories to include others with similar interests and common values.

We must also continue to embrace innovation and change to stay current with the needs of our members, our patients, and our society (eg, the Academy should be prepared to launch a new publication if it will better meet the interests and needs of members). The specialized interests of our members should be addressed, and we should add educators’ and researchers’ councils to the structure of the Academy to include these priorities in the mainstream of our field.

It is imperative that we grow the scientific knowledge base of the field. We need to advocate for enhancing our research capacity (following through with the wonderful start made by the Research Capacity Summit that was held in April 2005). Growth of support for rehabilitation and disability research within the National Institutes of Health and the National Institute for Disability and Rehabilitation Research must be encouraged by the creation of coalitions to support rehabilitation research that will include consumers as well as professionals.

The international rehabilitation community must be fully embraced as well. We in the United States have much to learn and much to offer our colleagues in other nations and international societies, and we need to increase our interaction and participation in the global community of medicine.

In conclusion, the dark future I have portrayed must not be allowed to come to pass. We, as individuals and a specialty, must have the courage of our convictions to think expansively, act decisively, and be motivated by our compassion. We must hold true to our values and beliefs. And, most importantly, we must test our every action and decision against what value it will bring to our patients and their families.

By never straying from our commitment to doing the right thing for our patients, we will shape a bright new era for our patients and ourselves.