Challenges and Opportunities in Academic Physiatry: An Environmental Scan.

ABSTRACT: Environmental scans determine trends in an organization's or field's internal and external environment. The results can help shape goals, inform strategic decision making, and direct future actions. The Association of Academic Physiatrists convened a strategic planning group in 2020, composed of physiatrists representing a diversity of professional roles, career stages, race and ethnicity, gender, disability status, and geographic areas of practice. This strategic planning group performed an environmental scan to assess the forces, trends, challenges, and opportunities affecting both the Association of Academic Physiatrists and the entire field of academic physiatry (also known as physical medicine and rehabilitation, physical and rehabilitation medicine, and rehabilitation medicine). This article presents aspects of the environmental scan thought to be most pertinent to the field of academic physiatry organized within the following five themes: (1) Macro/Societal Trends, (2) Technological Advancements, (3) Diversity and Global Outreach, (4) Economy, and (5) Education/Learning Environment. The challenges and opportunities presented here can provide a roadmap for the field to thrive within the complex and evolving healthcare systems in the United States and globally.

Climate Change and Physiatry: A Call to Proportional and Prospective Action.

ABSTRACT: Through increased temperature-related illness, exposure to wildfire smoke and air pollutants, and more frequent and intense natural disasters, climate change is disproportionately affecting the health of people with disabilities. Although the evidence behind the health effects of climate change is growing, there remain critical research gaps in the physiatric literature that must be addressed. Increased education throughout the medical-education continuum is also needed to prepare physiatrists to address the climate-related health effects impacting their patient populations. Physiatrists and their member organizations should advocate for policies that address climate change with a focus on the unique needs of their patient population and the inclusion of people with disabilities in the policy making process.

Pain and Addiction: The Distribution of Supply and Demand During the Opioid Epidemic.

ABSTRACT: A considerable portion of the opioid epidemic has been driven by physician-prescribed opioids for pain management. Thus, policies to address the epidemic must consider not only the resources available to manage addiction but those to manage acute and chronic pain as well. For the period 2017 to 2019, the authors sought to describe the distribution, by state, of indicators of the supply of resources to address pain and addiction (graduate medical education subspecialty training in pain and addiction, number of board-certified pain and addiction specialists, number of opioid treatment centers), as well as indicators of the demands for those services (opioid prescriptions, opioid overdose deaths), to identify states that seem to suffer from a mismatch between supply and demand. It was also sought to examine the relationships between these treatment resources and indicators of the magnitude of the opioid epidemic, through an exploratory correlational analysis. The resulting model may inform public policy by suggesting areas in need of greater graduate medical education training and more pain and addiction specialists and by suggesting hypotheses about the impact of these specialists on outcome that are worthy of further study.

Physical Medicine and Rehabilitation Milestone Evaluation Project: Development of Standardized Rotation-Specific Milestone-Incorporated Faculty-of-Resident Evaluation Tools.

ABSTRACT: This tri-institutional study describes the outcomes of utilization of newly developed, standardized, rotation-specific evaluations for faculty assessment of resident achievement of the physical medicine and rehabilitation milestones. Thirty-six physical medicine and rehabilitation faculty, representing three distinct academic institutions, completed a prestudy survey on the adequacy of the rotation-generic resident evaluation tools historically in use at each institution. During the 2016-2017 academic year, faculty in all three institutions consistently used a new set of rotation-specific milestone-incorporated evaluation tools. The same faculty completed surveys assessing the new evaluation tools 6 and 12 months later. Ordinal logistic regression was used to compare survey results before and after implementation of the rotation-specific milestone-incorporated evaluation tools. Results demonstrate high tool satisfaction scores, and a statistically significant improvement in the adequacy and specificity of the new evaluation tools compared with the old ones. There was also a statistically significant improvement in both faculty understanding of the milestones and faculty ability to assess the milestones with use of the new tools compared with the old ones. The implementation of standardized physical medicine and rehabilitation rotation-specific milestone-incorporated faculty-of-resident evaluation tools across three institutions improves faculty ability to assess resident overall performance specifically related to resident achievement of the milestones in each rotation.

The Value and Role of the Inpatient Rehabilitation Facility: Association of Academic Physiatrists Position Statement.

ABSTRACT: Although healthcare is always changing, the inpatient rehabilitation facility has indispensable and enduring roles in patient care, medical education, and research. For patients with complex medical and functional limitations, inpatient rehabilitation facility-level care fosters recovery and community reintegration and plays a strategic role in optimizing healthcare transitions from acute and to postacute settings. It is an incomparable and distinct zone for interprofessional education: the healthcare system is dependent on the inpatient rehabilitation facility as the epicenter for instruction to healthcare professionals on how to care for patients with complex rehabilitation needs. As healthcare evolves, patients' increasing medical complexity requires ongoing research focused on patients' evolving healthcare needs. The inpatient rehabilitation facility alone offers the requisite infrastructure to support such discovery. In this Association of Academic Physiatrists Position Paper, we provide a fresh perspective on the value proposition of the inpatient rehabilitation facility and advocate for this unique clinical environment as a critical component of contemporary healthcare.

Humanistic medicine in anaesthesiology: development and assessment of a curriculum in humanism for postgraduate anaesthesiology trainees.

BACKGROUND: An unintended consequence of medical technologies is loss of personal interactions and humanism between patients and their healthcare providers, leading to depersonalisation of medicine. As humanism is not integrated as part of formal postgraduate anaesthesiology education curricula, our goal was to design, introduce, and evaluate a comprehensive humanism curriculum into anaesthesiology training. METHODS: Subject-matter experts developed and delivered the humanism curriculum, which included interactive workshops, simulation sessions, formal feedback, and patient immersion experience. The effectiveness of the programme was evaluated using pre- and post-curriculum assessments in first-year postgraduate trainee doctors (residents). RESULTS: The anaesthesiology residents reported high satisfaction scores. Pre-/post-Jefferson Scale of Patient Perceptions of Physician Empathy showed an increase in empathy ratings with a median improvement of 12 points (range; P=0.013). After training, patients rated the residents as more empathetic (31 [4] vs 22 [5]; P<0.001; 95% confidence interval [CI]: 7-12) and professional (47 [3] vs 35 [8]; P<0.001; 95% CI: 9-16). Patient overall satisfaction with their anaesthesia provider improved after training (51 [6] vs 37 [10]; P<0.001; 95% CI: 10-18). Patients rated their anxiety lower in the post-training period compared with pretraining (1.8 [2.3] vs 3.6 [1.6]; P=0.001; 95% CI: 0.8-2.9). Patient-reported pain scores decreased after training (2.3 [2.5] vs 3.8 [2.1]; P=0.010; 95% CI: 0.4-2.8). CONCLUSIONS: Implementation of a humanism curriculum during postgraduate anaesthesiology training was well accepted, and can result in increased physician empathy and professionalism. This may improve patient pain, anxiety, and overall satisfaction with perioperative care.

State of the States: Growing Physiatry: Association of Academic Physiatrists Position Statement Addressing Academic Physiatry and Physical Medicine and Rehabilitation Growth.

The growth of physiatry in the United States is dependent on academic exposure at both the undergraduate and graduate medical education levels. Undergraduate medical education provides students with knowledge of physiatry, as well as proper understanding of human function, medical rehabilitation treatments, and of physiatrists as consultants. Graduate medical education contributes more directly to the total number of practicing physiatrists. This article presents disparities in medical student exposure to physiatry, physical medicine and rehabilitation residency positions, the number of practicing physiatrists, and physical medicine and rehabilitation-relevant patient care needs, by state. In the model, these disparities are highlighted to provide guidance and expose gaps/opportunities for targeted physiatric growth.

Graduate Medical Education Funding and Curriculum in Physical Medicine and Rehabilitation: A Survey of Physical Medicine and Rehabilitation Department Chairs.

This national survey highlights graduate medical education funding sources for physical medicine and rehabilitation (PM&R) residency programs as well as perceived funding stability, alignment of the current funding and educational model, the need of further education in postacute care settings, and the practice of contemporary PM&R graduates as perceived by PM&R department/division chairs. Approximately half of the reported PM&R residency positions seem to be funded by Centers of Medicare and Medicaid Services; more than 40% of PM&R chairs believe that their residency program is undersized and nearly a quarter feel at risk for losing positions. A total of 30% of respondents report PM&R resident experiences in home health, 15% in long-term acute care, and 52.5% in a skilled nursing facility/subacute rehabilitation facility. In programs that do not offer these experiences, most chairs feel that this training should be included. In addition, study results suggest that most PM&R graduates work in an outpatient setting. Based on the results that chairs strongly feel the need for resident education in postacute care settings and that most graduates go on to practice in outpatient settings, there is a potential discordance for our current Centers of Medicare and Medicaid Services graduate medical education funding model being linked to the acute care setting.

Improving Trainee Competency and Comfort Level with Needle Driving Using Simulation Training.

OBJECTIVE: To assess whether a combination of lecture and model simulation improves resident competency and comfort level with needle driving for interventional pain medicine procedures. DESIGN: Prospective, observational study. METHOD: Trainees who rotated through the University of California, Irvine, outpatient pain medicine clinic were recruited for the study. Subjects were given a brief lecture and completed a survey with questions regarding their level of comfort with interventional pain medicine procedures. This was followed by a timed trial on a training simulator where the objective was to drive a needle to the target. After the trial, the subject was then given a 30-minute practice session with the simulation model. The subject was then asked to repeat the timed trial and complete a post-simulation survey. RESULTS: All measures of the level of comfort increased significantly after subjects underwent the simulation training. In addition, subjects were able to significantly decrease their entrance time (P= 0.002), total time (P= 0.033), and vertical (P≤ 0.001) and horizontal deviation (P≤ 0.001) from the final target point after the simulation training. CONCLUSIONS: Our study demonstrates that simulation training may improve both trainee comfort level and competency with needle driving. After a brief lecture and a 30-minute training session with the simulator, subjective comfort measures and competency measures (more subjects were able to reach the target, vertical and horizontal deviations from the target decreased) were significantly improved. This suggests that simulation may be a helpful tool in teaching needle driving skills.

False positive radiographical evidence of pump catheter migration into the spinal cord.

Intrathecal drug delivery systems are becoming an increasingly common modality used by physicians to treat patients. Specifically, chronic spasticity secondary to multiple sclerosis (MS) may be treated with intrathecal baclofen (ITB) therapy when oral antispasmodics do not provide adequate relief. ITB therapy is effective, localizes drug delivery, and does not have the same degree of intolerable systemic effects often seen with oral and parenteral medications. As the use of intrathecal drug delivery systems has become more common, so has the incidence of adverse events. ITB administration requires the surgical implantation of indwelling catheters and a pump reservoir. Although this therapy is useful in treating spasticity, risks unique to intrathecal drug delivery systems include medication dosing errors, pump malfunction, infection, and catheter breakage or dislocation. To our knowledge intrathecal pump catheter migration into the spinal cord is a very rare complication with only 2 such complications reported. We present a case of an intrathecal baclofen pump catheter that was initially believed to have migrated into the spinal cord and the innovative use of cinefluoroscopy and digital subtraction used to identify catheter placement. Moreover, after confirmation of the catheter position within the spinal cord on magnetic resonance imaging (MRI) our team elected to perform a laminectomy, which demonstrated that the catheter was not in the spinal cord but was surrounded by arachnoid adhesions. We hope our efforts will provide the clinician insight into the common difficulties that arise and how best to troubleshoot them to serve this specific patient population and prevent potentially life-threatening complications.

The impact of major life events on the use of complementary and alternative medicine among individuals with chronic pain: a cross-sectional study.

CONTEXT: Chronic pain affects millions of Americans. Treating chronic pain can be difficult because it is a complex condition influenced by genetic makeup and physiological and psychological factors. The experience of major life events has also been found to affect the psychosocial functioning, health, and health behaviors of patients. Whereas the impact of major life events on the use of traditional medical practices has been explored, only one study to date has examined the relationship between major life events and use of complementary and alternative medicine (CAM). OBJECTIVE: This study examined the impact of major life events on the use of CAM among patients with chronic pain syndromes. DESIGN: Participants were consecutive patients seeking treatment at a pain clinic. SETTING: The study occurred at a tertiary center for pain management in Southern California. PARTICIPANTS: Participants were adult patients experiencing chronic pain for at least 6 mo, seeking treatment at a pain center. OUTCOME MEASURES: Participants completed a measure assessing their use of CAM modalities as well as their receptiveness to using previously unused CAM modalities, and they provided demographic information, including the occurrence of major life events, such as a job loss. RESULTS: A total of 199 adults with chronic pain participated in the study. The majority (91.6%) of chronic pain patients in the study reported using at least one form of CAM, with an average of at least five different forms of CAM. Individuals reported receptiveness to CAM modalities that they had not previously used (P < .05). Rates of CAM use were greater among those that had experienced a major life event in the prior 6 mo (P < .05). The most common major life events for this group included a compromised medical status, death of a loved one, financial hardship, a major geographical move, and altered family relationships. CONCLUSIONS: The study found that individuals with chronic pain frequently use CAM therapies, especially those who had recently experienced a major life event. Major life events may motivate patients with chronic pain to seek out different forms of CAM as a way to manage their pain.

Reflecting on pain management for patients with osteoarthritis and other rheumatic disorders: there's more to pain management than managing pain.

SUMMARY Medical progress is measured by advances in science and technology. The pace of discovery will surely accelerate. We are increasingly challenged not only to assimilate new information, but also to reconcile our learning with our art. We present the common clinical problem of managing pain in osteoarthritis as a paradigm for this dilemma in contemporary patient care. We do not yet have the understanding and interventions to do this optimally for all with osteoarthritis, leaving us with uncertainties as we struggle to care for these patients. In a world of growing complexity and sophistication we must not overlook the person who is our patient. It is easy to be seduced by electronic and informational advances, to be entranced by machinery, and to forget the unique individuality and needs of each patient. Osler taught that "the practice of medicine is an art, based on science". This doesn't change.

Exposure of the dorsal root ganglion to pulsed radiofrequency current in a neuropathic pain model of peripheral nerve injury.

The spinal nerve ligation model of neuropathic pain in rats, as originally described by Kim and Chung (Pain 50:355-363, 1992), provides an excellent venue to study the antinociception and modulation effects of pulsed radiofrequency (PRF) current in pain processing. We describe the procedure of application of PRF current near the exposed L5 dorsal root ganglion (DRG) in rats with L5 spinal nerve ligation injury-induced behavioral hypersensitivity. This method employs the direct visualization of the L5 DRG, allowing for confirmation of the location of the PRF probe adjacent to the DRG.

A physician-driven solution--the Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain medicine.

The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.

Application of pulsed radiofrequency currents to rat dorsal root ganglia modulates nerve injury-induced tactile allodynia.

BACKGROUND: Application of pulsed radiofrequency (PRF) currents to the dorsal root ganglia (DRG) has been reported to produce relief from certain pain states without causing thermal ablation. In this study, we examined the direct correlation between PRF application to DRG associated with spinal nerve injury and reversal of injury-induced behavioral hypersensitivity in a rat neuropathic pain model. METHODS: Neuropathic lesioning was performed via left L5 spinal nerve ligation on male adult Sprague-Dawley rats. Once the injured rats had developed tactile allodynia, one group was then assigned to PRF treatment of the L5 DRG and another group was assigned to the sham treatment to the DRG. Behavioral testing was performed on both the control and treated paws using the von Frey filament test before the surgery and at indicated days. The resulting data were analyzed using a linear mixed model to assess the overall difference between the treatment groups and the overall difference among the study days. Cohen's d statistic was computed from paired difference-from-baseline scores for each of the 14 study days after treatment and these measures of effect size were then used to descriptively compare the recovery patterns over time for each study group. RESULTS: Spinal nerve injury resulted in the development of behavioral hypersensitivity to von Frey filament stimulation (allodynia) in the hindpaw of the left (injury) side. Mixed linear modeling showed a significant difference between the treatment groups (P = 0.0079) and a significant change of paw withdrawal threshold means over time (P = 0.0006) for all 12 animals. Evaluation of Cohen's d (effect size) revealed that the PRF-treated animals exhibited better recovery and recorded larger effect sizes than the sham-treated animals on 10 of the 14 post-PRF treatment days and exhibited moderate-to-strong effects posttreatment at days 8 to 10 and at and beyond day 32. CONCLUSIONS: Findings from this study support that PRF of the DRG causes reversal of nerve injury (spinal nerve ligation)-induced tactile allodynia in rats. This allodynia reversal indicates that nonablative PRF acting via modulation of the DRG can speed recovery in nerve injury-induced pain.

Parental postoperative pain management: attitudes, assessment, and management.

OBJECTIVES: Previous studies suggested that parents frequently do not adequately treat postoperative pain that is experienced at home. Reasons for these parental practices have not been extensively studied. Aims of this study were to examine parental postoperative pain assessment and management practices at home as well potential attitudinal barriers to such pain practices. METHODS: This was a longitudinal study involving 132 parents of children who were aged 2 to 12 years and undergoing elective outpatient surgery. Parental attitudes about pain assessment and management were assessed preoperatively, and children's pain severity and analgesic administration were assessed postoperatively for the first 48 hours after discharge. RESULTS: Although postoperative parental ratings indicated significant pain, parents provided a median of only 1 dose of analgesics (range: 0-3) during the first 48 hours after surgery. In the attitudinal survey, parents' responses have indicated significant barriers. For example, 52% of parents indicated that analgesics are addictive, and 73% reported worries concerning adverse effects. Also, 37% of parents thought that "the less often children receive analgesics, the better they work." Regression analysis demonstrated that, overall, more preoperative attitudinal barriers to pain management were significantly associated with provision of fewer doses of analgesics by parents (P < .05). CONCLUSIONS: Parents detected pain in their children yet provided few doses of analgesics. Parents may benefit from interventions that provide them with information that addresses individual barriers regarding assessing and treating pain.