Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 4 , Pages 408-412, April 2007

Through the Looking Glass: A Personal View of the Field of Rehabilitation Medicine. The 56th John Stanley Coulter Memorial Lecture

Presented at the American Congress of Rehabilitation Medicine, September 2006, Boston, MA.

  • Martin Grabois, MD

      Affiliations

    • Corresponding Author InformationCorrespondence to Martin Grabois, MD, Dept of Physical Medicine and Rehabilitation, Baylor College of Medicine, 1333 Moursund Ave, A-221, Houston, TX 77030.

Departments of Physical Medicine and Rehabilitation and Anesthesiology, Baylor College of Medicine, Houston, TX.

Article Outline

Abstract 

Grabois M. Through the looking glass: a personal view of the field of rehabilitation medicine. The 56th John Stanley Coulter Memorial Lecture.

This lectureship reviews the past, present, and future of the field of physical medicine and rehabilitation (PM&R) from the clinical, educational, and research points of view. I make recommendations for the field on how members of the various PM&R associations can make a difference in mapping the future.

Key Words: Physical medicine, Rehabilitation

 

ISTAND BEFORE YOU to give the 56th John Stanley Coulter Memorial Lecture at this annual meeting of the American Congress of Rehabilitation Medicine (ACRM) in Boston, Massachusetts. It is very humbling to be recognized by one’s peers and to realize that I have been given the opportunity to carry forward John Stanley Coulter’s ideals through this memorial lecture.

Before I move forward, I want to thank a number of people, as I have done on many previous occasions, who continue to stand with me and support me.1, 2 I acknowledge and thank the faculty and staff of the Baylor College of Medicine/University of Texas−Houston (UTHSC-H) Physical Medicine and Rehabilitation Alliance for their ongoing support and encouragement. A special thank you and recognition to Donna Jones, my senior administrative associate. She is my right hand at work. I also recognize and thank my wife, Ellen, and children, Sarah and Meredith, and Meredith’s husband, Brian, and our granddaughter, Ava, for their help and support. They tolerate my going out of town many weekends throughout the year and my being engrossed with physical medicine and rehabilitation (PM&R) even when I was at home. Finally, I would like to thank the awards committee, the ACRM board of governors, and especially you, the membership, who have awarded me this honor and have allowed me to be your president for 2 previous consecutive terms (2000−2001, 2001−2002).

I refer you to my past 2 ACRM presidential addresses1, 2 and to my American Academy of Physical Medicine and Rehabilitation (AAPM&R) Zeiter Lecture.3 The ideas and concepts I proposed then are still valid and serve as a springboard for this lecture.

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Tribute to John Stanley Coulter 

A few, but not all, John Stanley Coulter Memorial Lectures have acknowledged why this lectureship is given in honor of John Stanley Coulter. Let me continue this tradition and pay tribute to him and his accomplishments.4, 5, 6, 7, 8 John Stanley Coulter (1885−1949) was the third president of ACRM (1925−1926), treasurer (1926−1949), and served as assistant editor of its official journal, Archives of Physical Therapy, then Archives of Physical Medicine, before it became Archives of Physical Medicine and Rehabilitation.4 In 1947, along with Frank Krusen, MD, he helped to establish the American Board of Physical Medicine and Rehabilitation (ABPMR) and was an ABPMR charter member.6 He was also the first president of the AAPM&R (1938−1939). One could call him, as Kristian Hansson, MD, did in the First Coulter lecture, one of the “Fathers of Physical Medicine.” Hansson noted, “All human enterprises have leaders and so has medicine. Physical Medicine was fortunate to have such a leader in Doctor John Stanley Coulter. He proved his leadership in many ways, as a soldier, as an author and editor, as a physician and as a friend to those who sought his advice.”4(p629)

Despite his many years in the field and his tremendous contributions to the development of PM&R, he never slowed his dynamic pace as a devoted worker and inspiring leader. He was a man of vision whose eyes were never off the rainbow and, in the closing years of his life, he saw the founding of AAPM&R. He is among a number of physicians who helped the field gain recognition as a full-fledged specialty.5 This lectureship is devoted to John Stanley Coulter and all the early pioneers who built the foundation for this field. To them we owe a great deal.

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Personal Observations 

On a personal note, I am a product of the Vietnam War, and my entering into PM&R is a result of that war. It was in Vietnam that I gave significant thought to my future, and decided PM&R was the specialty for me. It met my goals of being clinically involved with patients, dealing with long-term patient care, entering a specialty with a shortage of physicians, and working in a specialty that improves the quality of life of patients whom we treat. Now I stand before you 38 years later to tell you it has been, and continues to be, everything for which I ever hoped.9

PM&R has been not only my vocation but also my passion. I strive for excellence in myself, in our department, and in the field. I continue to believe in the interdisciplinary process and in making our patients our highest priority. I believe that if you put patients first and do what is right for them, you and the field will prosper. In Mary Switzer’s words, “At the bottom of any program, and at the bottom of any set of statistics we are doing, is the consumer, or the patient, or the clients, or the person that we are trying to work with.”10(p205) If an organization does not meet people’s needs, there is no reason for it to exist.

Since I entered the field as a resident in 1969, and became acting chairman of PM&R at Baylor College of Medicine (BCM) in 1977, I have strived locally, nationally, and internationally to move the field forward. With your help, we have done so. I do have a regret, and that is never having the opportunity to hone my research skills. However, as a clinician and educator, I have supported research in our department and in the field. I recognize its importance and our need to expand and enrich it.

Rehabilitation medicine is now recognized as helping more people than ever before. However, we face new challenges in meeting our mission and goals. There is an assault on clinical care by decreased reimbursement and enforcement of the 75% rule. There is a lack of evidence-based research to prove what we do really works and, finally, there is leveling off of the academic productivity of our field. All of these are significant issues. If we are to continue to move the field forward and to serve people with disabilities, we will need to address each of these issues head on.

I know most of you are researchers, not physicians, so please indulge me as I discuss the entire field from a service, clinical, academic, educational, and research point of view. I think we all realize that, if we are to succeed, it will be through a partnership of administrators, educators, clinicians, and researchers.

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Past and Current Status 

Let me, with the help of Gerben DeJong’s address entitled, “Growth and Development of the Rehabilitation Industry,”11 presented at an ACRM meeting in Florida in 2004, give you insight into where we were, where we are now, and where we need to go. To address the years before 1970, I refer you to Krusen’s Zeiter Lecture,12 Rose’s Coulter Lecture,13 and Kottke’s Coulter Lecture.5 These lectures summarize the history of the field, from its onset to the late 1960s.

DeJong has described a 35-year prospective from 1970 to the present.11, 14 It just happens to coincide with my career in PM&R, starting with my residency in 1969.

In the years 1973 to 1983, we struggled for recognition as we had since our specialty began in 1948. Unfortunately, for those of you who were in the field then, rehabilitation medicine was not glamorous. It was often considered a backwater of American medicine, until one had a friend or relative with a disability who needed rehabilitation. At the same time, we had an uneasy relationship with the disability and independent living movement, which I think still exists today. That relationship mirrored the devalued status of people with disabilities at that time. The field was largely hospital-based and we had difficulties obtaining rehabilitation bed space. We had an insufficient research base for the field, and research funding was almost exclusively through the U.S. Department of Education. While we had outcome measures (ie, functional status measures), there were no benchmarking capabilities.

It was during this era that I became chairman at BCM and became active in national rehabilitation medicine organizations. At BCM we concentrated on improving the educational component of our program and expanded our research activities in successive 5-year plans.

The years 1983 to 1993 were the golden years of rehabilitation medicine. Medicare began to fund health care for the elderly in the early 1960s and later diagnosis-related groups for acute care increased the need and demand for rehabilitation services. In fact, rehabilitation facilities proliferated as for-profits entered the picture. Demand for physiatrists, allied health professionals, and researchers resulted in increased salaries, an increase in medical schools with rehabilitation departments, and a significant increase in American medical graduates entering the field. In research, the National Center for Medical Rehabilitation Research (NCMRR) became a reality, the Americans with Disabilities Act was enacted, and benchmarking via the FIM instrument and other scales was firmly established.

It was during this time that we established at BCM rehabilitation units in almost all our affiliated hospitals; we started developing clinical subspecialties, especially brain injury, and we continued moving our research endeavor forward.

The era of managed care and industry consolidation started in 1993 and continued through 1998. Managed care started on the West coast and moved east as the cost of health care significantly increased. This ultimately involved not only private plans but also Medicare, Medicaid, and worker’s compensation. Independent rehabilitation facilities (IRFs) felt threatened (sounds like today) and this threat resulted in the establishment and growth of skilled nursing facilities (SNFs) and long-term care hospitals (LTCHs). Therapy teams were reorganized to increase efficiency and therapy assistants were used increasingly. Reimbursement rates for services were held in check and we saw, in fact, some cuts in payments for services by health care professionals and facilities. Health care facilities underwent significant mergers or acquisitions, and the growth of academic rehabilitation medicine programs plateaued.

By this time at BCM, we realized that we could not go it alone, so we established a partnership with UTHSC-H. It allowed both of us to continue to grow and expand on a more cost-effective and efficient basis. Formed in 1996, the Alliance is 65 faculty strong, and works with all 9 major health care institutions in the Texas Medical Center. The Alliance covers 5000 beds, 250+ of which are dedicated to rehabilitation. It collaborates and/or integrates medical students, residents, fellows, and continuing medical education programs, and sponsors over 98 active research projects with over 51 grants totaling $40 million.8

By 1998 and through 2005, we had a reprieve from managed care, as its expansion came to a halt. Prospective payment system came to the field, with traditional patients returning to IRFs and with significant increase in money for facilities. While LTCHs proliferated, SNFs have had significant financial difficulties because of change in the payment system by Medicare. Innovative rehabilitation products appeared such as day-hospitals, and there was a proliferation of outpatient and home health care rehabilitation programs. Within our Alliance, we actively pursued these innovative opportunities.

Finally in 2005, the federal squeeze came into play and it continues to be the dominant factor affecting rehabilitation medicine now. Medicare started enforcing the 75% rule, local intermediary guidelines for rehabilitation took hold, and a therapy cap was put in place. Rehabilitation facilities took a major hit in income as the government tried to deal with deficits by cutting Medicare funding. Research funding, which had increased in previous years, remained flat or was cut.

One gets the feeling we are treading water in the field and in individual departments, especially in the area of clinical and research activities.

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Current Status and Future Opportunities 

Let us consider this history as a background to our current status and, more importantly, future opportunities.

Clinical Care 

In the clinical care area, we have been accepted as a field by most of our medical colleagues in other parts of the United States. We are better known to the public, but still have a long way to go in this area. We have expanded from the physical medicine model to the rehabilitation model, and in the rehabilitation model we are now including musculoskeletal and pain rehabilitation. The 75% rule has put a damper on inpatient rehabilitation units, but many units recognize the value and benefit of our services.

Now is the time to look at new opportunities, and I would like to address 2 of them. The first is an integrated model of care. We are experts in interdisciplinary care on our inpatient rehabilitation units. I now propose we take this model to other health care entities such as SNFs, LTCHs, day-hospitals, outpatient services, home health care services, and nursing home entities. I propose programs that will develop a fully integrated, comprehensive continuum of care for our patients. It will expedite transfer of patients and their pertinent information to provide uninterrupted care. It will also avoid costly and time-consuming re-evaluations of patients and improve the continuum of rehabilitation care that our patients deserve.

The second area is to expand clinical care with emphasis on nontraditional diseases that result in disability. We have already done this in pain management, but we also need to expand the interdisciplinary model to other diagnoses. I would also propose new rehabilitation programs such as what at Memorial Hermann/TIRR we call “specialty care.” We use specialty care for neuromuscular disease rehabilitation such as multiple sclerosis, Parkinson’s, and peripheral neuropathy. There are other areas we have not emphasized, such as cardiac and pulmonary rehabilitation, burn rehabilitation, post-transplant surgery, and cancer rehabilitation, that are ripe for expansion. This is currently an area in which AAPM&R could take a leadership role.

Service 

I feel we may have regressed in giving service to our organization. As more academic and private rehabilitation medicine professionals, both medical (MD) and doctoral (PhD), want to increase billing or obtain more grants to make a healthy bottom line, there is less of a commitment to service. It is not that our organization does not have excellent leadership, but it could be more diverse and intense. Our members need to be more involved in local and state organizations because the national organization cannot do everything for everybody in all the local areas and in all 50 states.

Dorothea Glass, MD, asked, in her ACRM presidential address, “What am I doing and what more can I do to promote this Congress and its goals?”15(p79) I feel each of us owes it to the field to get involved at either the local, state, or national level. At the national level, we need to be much more involved in ACRM. I ask you to look to your right, look to your left, and ask each other at the close of this lecture, What one more thing you will do to promote the field?

I also ask you to reread Robert Frank’s Coulter Lecture entitled, “Lessons from the Great Battle: Health Care Reform, 1992−1994.”16 In it he lays out the principles of health care reform. He emphasizes lessons learned and what these lessons tell us to do in the future. I especially draw your attention to his principle that health care reform enhances the importance of professional groups and their ability to influence the process. That is why a strong and vibrant ACRM is so important. You can help by becoming active and working to increase ACRM membership. We need to have a strong organization that can work with the Association of Academic Physiatrists (AAP) and AAPM&R to expand academic, clinical, and research activities.

Education 

In education we have a steady stream of good residents and postdoctoral PhDs in the field. They are better educated in rehabilitation medicine, more thoughtful, and demanding much more attention.

PM&R residents want more outpatient experience and more musculoskeletal pain experience, which is difficult to achieve within a reimbursement formula that favors inpatient rehabilitation. We need, therefore, to continue to work to change that formula and to encourage rotations in this area.

Now is the time for every residency program to establish outpatient multidisciplinary musculoskeletal, spine, pain, and sports medicine programs. I am not talking about block clinics; I am talking about true integrated rehabilitation programs in the area of pain.

There are only 66 independent PM&R departments in 139 medical schools and the number has not changed significantly over the past 10 years. Now is the time for AAP to take a leadership role in improving this situation with new programs or reinvention of old programs such as “Adopt a Medical School.”

Resident education in research in rehabilitation medicine needs to be re-emphasized and the article by Boninger et al,17 “Resident Research Education in Physical Medicine and Rehabilitation: A Practical Approach,” outlines a road map to achieve this goal.

While emphasizing resident education, I do not want to forget the nonphysiatrist rehabilitation medicine professionals. We need better integration of educational programs and more support for research fellowships and postdoctoral experiences.

Research 

If I had to emphasize 1 area where we still lag, over the others, I feel it would be in the area of research. This is in spite of the National Institute on Disability and Rehabilitation Research, NCMRR, and the Veterans Affairs research programs. Most grant research has limited physician involvement, and we have not provided adequate science for what we do. We have done better in the clinical, observational, and psychosocial vocational areas than in the translational bioscience areas.

As president of the Foundation for PM&R, I was delighted to help provide leadership as the Foundation sponsored the Rehabilitation Medicine Summit: Building Research Capacity in association with AAPM&R, AAP, and ACRM. Walter Frontera, MD, PhD, led a wonderful team that provided a blueprint to move us forward.18 The Summit came up with 8 priorities to improve and expand research in rehabilitation medicine. They are:

1.The need for a coalition of professional groups and consumer organizations to create a national research agenda and to develop specific objectives and action plans.

2.The need for training of new investigators, both MD and PhD.

3.The need to support the career paths of rehabilitation medicine researchers.

4.The need to increase multidisciplinary research among individuals, organizations, and fields.

5.The need for improved infrastructure with more programs, personnel, equipment, space, and support staff.

6.The need for funding agencies to assign sufficiently high priority to medical rehabilitation research with increased funding; the need to establish an independent institute within National Institutes of Health (NIH); and the need for expanded participation of rehabilitation scientists in scientific review panels.

7.The need to recognize scientific discovery as an institutional and organizational core set of values within professional organizations. They must include rehabilitation medicine research as an important component of their mission statement. ACRM rose to the occasion by changing its mission statement: to enhance the lives of persons living with disabilities through a multidisciplinary approach to rehabilitation and to promote rehabilitation research and its application to clinical practice.

8.Finally, we as a field need to have appropriate metrics in place to measure our successes or failures. We should measure the number of rehabilitation research trainers we have, the size of our rehabilitation research cadre, the productivity of our endeavors, and the amount of funds federal agencies spend on rehabilitation research.

Articles by Wagner et al19 on measuring rehabilitation research capabilities and Verville and DeLisa20 on the evolution of NIH options for rehabilitation research, as well as comments by Laurence21 on the establishment of a National Institute of Medical Rehabilitation Research (NIMRR), provide valuable support for the training of additional researchers and for the establishment of an NIMRR.

However, I am concerned, as with other summits, with the implementation of these recommendations. Yes, we have started to work on Friends of Rehabilitation Medicine Research and are working to establish an NIMRR. But so much more remains to be done. I challenge the Foundation for PM&R to provide leadership and help ACRM, AAP, AAPM&R, and others in the field to implement the recommendations of the Research Summit. Each organization should take on 1 or 2 initiatives to advance science and advocate for increased rehabilitation medicine research. I think ACRM can and should take a leadership role in these political activities in light of its mission to support clinically relevant interdisciplinary researchers in rehabilitation science.

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Conclusions 

I have tried to provide you with a personal view of the field of rehabilitation medicine as well as the challenges we face. I have made recommendations for initiatives to meet those challenges.

We should be proud of our history and our accomplishments, but we cannot continue to live in the past. We need to learn from our history and look to the future as leaders and shapers of the future. John Stanley Coulter would have been proud to step up and step forward as a leader of the field, to continue to move it forward, as I ask you to do today.

I ask you to become directly involved and to support 1 or more of the following initiatives.

1.Develop at least 1 new joint clinical-research rehabilitation program at your institution.

2.Increase your activity in the area of service by joining and becoming active in at least 1 local, state, or national rehabilitation medicine organization, especially ACRM.

3.Promote a strong and vibrant ACRM by not only getting involved but by also securing at least 1 new active member for ACRM.

4.Visit locally with a consumer of rehabilitation services or visit in Washington, DC, with your congressman and senators to politically promote our clinical, education, and research rehabilitation agendas.

5.Work to expand PM&R programs to every medical school and hospital in the United States.

6.Participate in at least 1 research project annually and present and publish its findings.

7.Make a donation to the Foundation for PM&R to expand educational and research opportunities in the field.

8.Work with at least 1 consumer organization to partner in improving the quality of life of people with disabilities.

9.Demand that AAP, ACRM, and AAPM&R develop an effective partnership to move the agenda of people with disabilities forward, in association with consumer groups. It is time for BAAR, the communication forum for leaders of the AAPM&R, AAP, and ABPMR, to interact and to move from a communication vehicle to a leadership role.

10.Step into a leadership role in the field, whether it is a clinical, educational, research, or service role. You will help make a significant contribution to the field, receive great satisfaction and, perhaps, be satisfied enough to take on additional challenges.

I also challenge the national rehabilitation medicine organizations to provide individual members with leadership to accomplish these goals. I ask AAP to make a priority of reinventing and expanding academic programs and their educational component. I ask AAPM&R to support expansion of clinical activities. I ask the Foundation for PM&R to work with all 3 organizations, but to work especially with ACRM to implement the recommendations of the rehabilitation medicine research summit.

As I have noted previously, you can look at the glass as half-full or half-empty. I must admit, lately, I have looked at it as half-empty. After reading the history of the field and what our founders had to tackle, I understand once again that the glass is half-full. Work with me and work with ACRM to make the glass overflow.

As Ted Cole22 noted in his Zeiter Lecture, history shows that the evolution of medical rehabilitation is a cyclic phenomenon. It is difficult to change when times are good. It is much easier to change when troubles arise. Well, trouble is increasing in the field despite things being relatively good. So now is the time to become active and get involved. As we peer through the looking glass, we can learn from the past, embrace the present, and actively and aggressively move forward to face the challenges of the future of rehabilitation medicine.

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References 

  1. Grabois M. The paths we chose: to succeed or not to succeed. Arch Phys Med Rehabil. 2002;83:147–149
  2. Grabois M. The American Congress of Rehabilitation Medicine: where do we go from here?. Arch Phys Med Rehabil. 2003;84:1097–1099
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 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

PII: S0003-9993(07)00089-5

doi:10.1016/j.apmr.2007.02.001

Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 4 , Pages 408-412, April 2007

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