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.

Blinding, sham, and treatment effects in randomized controlled trials for back pain in 2000-2019: A review and meta-analytic approach.

BACKGROUND: Blinding aims to minimize biases from what participants and investigators know or believe. Randomized controlled trials, despite being the gold standard to evaluate treatment effect, do not generally assess the success of blinding. We investigated the extent of blinding in back pain trials and the associations between participant guesses and treatment effects. METHODS: We did a review with PubMed/OvidMedline, 2000-2019. Eligibility criteria were back pain trials with data available on treatment effect and participants' guess of treatment. For blinding, blinding index was used as chance-corrected measure of excessive correct guess (0 for random guess). For treatment effects, within- or between-arm effect sizes were used. Analyses of investigators' guess/blinding or by treatment modality were performed exploratorily. RESULTS: Forty trials (3899 participants) were included. Active and sham treatment groups had mean blinding index of 0.26 (95% confidence interval: 0.12, 0.41) and 0.01 (-0.11, 0.14), respectively, meaning 26% of participants in active treatment believed they received active treatment, whereas only 1% in sham believed they received sham treatment, beyond chance, that is, random guess. A greater belief of receiving active treatment was associated with a larger within-arm effect size in both arms, and ideal blinding (namely, "random guess," and "wishful thinking" that signifies both groups believing they received active treatment) showed smaller effect sizes, with correlation of effect size and summary blinding indexes of 0.35 (p = 0.028) for between-arm comparison. We observed uniformly large sham treatment effects for all modalities, and larger correlation for investigator's (un)blinding, 0.53 (p = 0.046). CONCLUSION: Participants in active treatments in back pain trials guessed treatment identity more correctly, while those in sham treatments tended to display successful blinding. Excessive correct guesses (that could reflect weaker blinding and/or noticeable effects) by participants and investigators demonstrated larger effect sizes. Blinding and sham treatment effects on back pain need due consideration in individual trials and meta-analyses.

Constructing a Shared Mental Model for Feedback Conversations: Faculty Workshop Using Video Vignettes Developed by Residents.

Introduction: Providing feedback is a fundamental principle in medical education; however, as educators, our community lacks the necessary skills to give meaningful, impactful feedback to those under our supervision. By improving our feedback-giving skills, we provide concrete ways for trainees to optimize their performance, ultimately leading to better patient care. Methods: In this faculty development workshop, faculty groups used six feedback video vignettes scripted, enacted, and produced by residents to arrive at a shared mental model of feedback. During workshop development, we used qualitative analysis for faculty narratives combined with the findings from a focused literature review to define dimensions of feedback. Results: Twenty-three faculty (physical medicine and rehabilitation and neurology) participated in seven small-group workshops. Analysis of group discussion notes yielded 343 codes that were collapsed into 25 coding categories. After incorporating the results of a focused literature review, we identified 48 items grouped into 10 dimensions of feedback. Online session evaluation indicated that faculty members liked the workshop's format and thought they were better at providing feedback to residents as a result of the workshop. Discussion: Small faculty groups were able to develop a shared mental model of dimensions of feedback that was also grounded in medical education literature. The theme of specificity of feedback was prominent and echoed recent medical education research findings. Defining performance expectations for feedback providers in the form of a practical and psychometrically sound rubric can enhance reliable scoring of feedback performance assessments and should be the next step in our work.

Faculty feedback that begins with resident self-assessment: motivation is the key to success.

CONTEXT: The seeking and incorporating of feedback are necessary for continuous performance improvement in medicine. We know that beginning feedback conversations with resident self-assessment may reduce some of the tensions experienced by faculty staff. However, we do not fully understand how residents experience feedback that begins with self-assessment, and whether any existing theoretical frameworks can explain their experiences. METHODS: We conducted a constructivist grounded theory study exploring physical medicine and rehabilitation residents' experiences as they engaged in a structured self-assessment and faculty staff feedback programme. Utilising purposive sampling, we conducted 15 individual interviews and analysed verbatim transcripts iteratively. We implemented several procedures to enhance the credibility of the findings and the protection of participants during recruitment, data collection and data analysis. After defining the themes, we reviewed a variety of existing frameworks to determine if any fitted the data. RESULTS: Residents valued self-assessment followed by feedback (SAFF) and had clear ideas of what makes the process useful. Time pressures and poor feedback quality could lead to a process of 'just going through the motions'. Motivation coloured residents' experiences, with more internalised motivation related to a more positive experience. There were no gender- or year of training-related patterns. CONCLUSIONS: Self-determination theory provided the clearest lens for framing our findings and fitted into a conceptual model linking the quality of the SAFF experience and residents' motivational loci. We identified several study limitations including time in the field, evolving characteristics of the SAFF programme and the absence of faculty voices. We believe that by better understanding residents' experiences of SAFF, educators may be able to tailor the feedback process, enhance clinical performance and ultimately improve patient care.

Entrustable Professional Activities For Residency Training in Physical Medicine and Rehabilitation.

Entrustable professional activities are observable units of professional practice that can potentially provide a link between competency-based medical education and clinical practice. The authors, part of a subcommittee of the Association of Academic Physiatrists Education Committee, identified a set of entrustable professional activities that would serve residency training programs in the specialty of physical medicine and rehabilitation. Using a modified Delphi process, residency program directors in the field reviewed and validated a set of entrustable professional activities. The final set of 19 entrustable professional activities is presented in this article.

Clinical Reasoning Workshop: Cervical Spine and Shoulder Disorders.

INTRODUCTION: Information processing and cognitive factors may be a cause of physician diagnostic errors. While the conceptual framework of dual processing in clinical reasoning is widely accepted, how can residents be taught to switch between automatic and reflective modes, and will doing so improve their decision making? Developing effective clinical reasoning habits while in training may facilitate progression to expertise, reduce diagnostic errors, and improve patient safety. METHODS: This workshop allows residents to practice engaging in and toggling between both modes of information processing using exemplar musculoskeletal vignettes. Originally implemented with a group of 26 physical medicine and rehabilitation residents, the workshop includes pre- and posttests, small-group learning, and a small-group competition. RESULTS: Posttest scores improved on pretest scores. In an online session evaluation, residents indicated they liked the workshop and thought it improved their diagnostic ability. DISCUSSION: This workshop, which includes team- and case-based learning, key features assessment, dual processing theory, and gamification, was effective in engaging residents and resulted in high resident satisfaction and perception of increased ability to tackle clinical problems. Faculty time required was moderate after the initial setup, which in our case primarily involved uploading content into an online learning management system.

Clinical Reasoning Workshop: Lumbosacral Spine and Hip Disorders.

Introduction: Helping physicians-in-training develop effective clinical reasoning skills may facilitate progression to expertise, reduce diagnostic errors, and improve patient safety. Using our previous experience, we developed a workshop that reviews musculoskeletal lumbar spine and hip conditions. This workshop also uses deductive and inductive modes of clinical reasoning and provides opportunities for learners to practice toggling from one to another while reviewing. Methods: Using exemplar musculoskeletal vignettes, this workshop allows residents to practice engaging and toggling between both modes of information processing. This workshop also includes pre- and posttests, small-group learning, and a small-group competition. Results: The workshop was implemented with a group of 26 physical medicine and rehabilitation residents. Although residents did well on the pretest, the workshop improved their test performance. Residents liked the workshop and thought it improved their diagnostic ability. Discussion: A workshop that included team- and case-based learning, key features assessment, script theory, and gamification was effective in engaging residents and resulted in high resident satisfaction and the perception of increased ability to tackle clinical problems. Learning from our experience with the previous workshop resulted in significant reduction in faculty time required, and increased the number of residents who were able to complete both pre- and posttests.

A Randomized, Double-Blind, Placebo-Controlled Study of Neuromuscular Electrical Stimulation (NMES) use for Recovery after Elective Total Hip Replacement Surgery.

Early physical activity has been proven to accelerate functional recovery after total hip replacement (THR). Weightbearing intolerance secondary to postoperative pain inhibits participation in physical therapy and limits the achievement of functional independence. Neuromuscular electrical stimulation (NMES) has been shown to improve pain and accelerate recovery. This study focused on the effects of NMES on weightbearing pain. The primary objective of this study was to compare the efficacy of NMES versus placebo in the reduction of pain and the use of opiate medications in the treatment of patients during weightbearing exercises after THR. A secondary objective was to assess the use of NMES during weightbearing exercise and its effects on function, hospital length of stay, and disposition planning. This was a randomized, doubleblinded, placebo-controlled study performed with subjects obtained from an outpatient orthopaedic service. Subject underwent elective THR. The NMES device was provided to all subjects; active and a control group were assigned different intensity levels of stimulation. Twenty-nine subjects participated in the study: 15 in the active and 14 in the control group. Data, including pain assessment, opiates use, function, hospital length of stay in days, and disposition was recorded and analyzed. Both control and active groups showed no significant difference on the pain visual analog scale at various postoperative time intervals, length of inpatient hospital stay, and days on opiate medications.

Predicting Performance on the American Board of Physical Medicine and Rehabilitation Written Examination Using Resident Self-Assessment Examination Scores.

BACKGROUND: Studies across medical specialties have shown that scores on residency self-assessment examinations (SAEs) can predict performance on certifying board examinations. OBJECTIVE: This study explored the predictive abilities of different composite SAE scores in physical medicine and rehabilitation and determined an optimal cut-point to identify an "at-risk" performance group. METHODS: For our study, both predictive scores (SAE scores) and outcomes (board examination scores) are expressed in national percentile scores. We analyzed data in graduates of a physical medicine and rehabilitation residency program between 2008 and 2014. We compared mean, median, lowest, highest, and most recent score among up to 3 SAE scores with respect to their associations with the outcome via linear and logistic regression. We computed regression/correlation coefficient, P value, R (2), area under the curve, sensitivity, specificity, and predictive values. Identification of optimal cut-point was guided by accuracy, discrimination, and model-fit statistics. RESULTS: Predictor and outcome data were available for 88 of 99 residents. In regression models, all SAE predictors showed significant associations (P ≤ .001) and the mean score performed best (r = 0.55). A 1-point increase in mean SAE was associated with a 1.88 score increase in board score and a 16% decrease in odds of failure. The rule of mean SAE score below 47 yielded the highest accuracy, highest discrimination, and best model fit. CONCLUSIONS: Mean SAE score may be used to predict performance on the American Board of Physical Medicine and Rehabilitation-written examination. The optimal statistical cut-point to identify the at-risk group for failure appears to be around the 47th SAE national percentile.

Assessing blinding in trials of psychiatric disorders: a meta-analysis based on blinding index.

The assessment of blinding in RCTs is rarely performed. Currently most studies that do report data on evaluation of blinding merely report percentages of correct guessing, not taking into account correct guessing by chance. Blinding assessment using the blinding index (BI) has never been performed in a systematic review on studies of major psychiatric disorders. This study is a systematic review of psychiatric randomized control trials using the BI as a chance-corrected measurement of blinding, a tool to analyze and understand the patterns of blinding across studies of major psychiatric disorders with available data. Of 2467 psychiatric RCTs from 2000 to 2010, 66 reported on blinding and 40 studies were found to have enough information on evaluation of blinding to be analyzed using the BI. The experimental treatment groups had an average BI value of 0.14 and the control groups had an average BI value of 0.00. The most common BI scenario was random-random, indicating ideal blinding. A positive correlation between effect size and more correct guesses was also found. Overall, based on BI values and the most common blinding scenario, the published articles on major psychiatric disorders from 2000 to 2010, which reported on blinding assessment for patients, were effectively blinded.

Blinding measured: a systematic review of randomized controlled trials of acupuncture.

Background. There is no agreement among researchers on viable controls for acupuncture treatment, and the assessment of the effectiveness of blinding and its interpretation is rare. Purpose. To systematically assess the effectiveness of blinding (EOB) in reported acupuncture trials; to explore results of RCTs using a quantitative measure of EOB. Data Sources. A systematic review of published sham RCTs that assessed blinding. Study Selection. Five hundred and ninety studies were reviewed, and 54 studies (4783 subjects) were included. Data Extraction. The number of patients who guessed their treatment identity was extracted from each study. Variables with possible influence on blinding were identified. Data Synthesis. The blinding index was calculated for each study. Based on blinding indexes, studies were congregated into one of the nine blinding scenarios. Individual study characteristics were explored for potential association with EOB. Limitations. There is a possibility of publication or reporting bias. Conclusions. The most common scenario was that the subjects believed they received verum acupuncture regardless of the actual treatment received, and overall the subject blinding in the acupuncture studies was satisfactory, with 61% of study participants maintaining ideal blinding. Objectively calculated blinding data may offer meaningful and systematic ways to further interpret the findings of RCTs.

Immediate and follow-up effects of a brief disability curriculum on disability knowledge and attitudes of PM&R residents: a comparison group trial.

BACKGROUND: Humanistic attitudes are essential in physicians and therefore supporting them is a key component in graduate medical education (GME). The importance of a physician's attitude toward people with disability is especially relevant within the rehabilitation discipline, as prevailing attitudes and misconceptions can be potential barriers to successful diagnosis and treatment. AIM: This study was designed to examine the relationship between participation in a brief disability sensitivity training and knowledge of disability and attitudes of physical medicine and rehabilitation (PM&R) residents toward people with disability. METHODS: A daylong training for residents consisted of lectures and a panel presentation that covered (1) disability facts, (2) personal stories of people with disabilities, and (3) medical evaluation of disability. The presentations were followed by a simulation experience where resident pairs (one assigned to a wheel chair, the other a "caretaker") performed various tasks. This was followed by a group discussion of their experience. Three instruments were administered prior to the training: (1) a brief demographic questionnaire, (2) 30 multiple choice questions measuring various aspects of knowledge about disability, and (3) the Scale of Attitudes toward Disabled Persons, Form R (SADP). After the training experience, the knowledge instrument and the SADP were re-administered along with a series of items to measure various aspects of students' satisfaction with the training. The three instruments described were re-administered 3 months post-training. RESULTS: There was significant immediate gain in both the disability knowledge and the attitude scores among trainees as compared to a control group of physiatry residents in standard medical training. Knowledge gains of the disability sensitivity training group did not persist, but attitude toward disability gains remained at the 3 months follow up. CONCLUSION: After a brief curriculum in disability knowledge and sensitivity for PM&R physicians in training, there was a short-term improvement in disability knowledge and an improvement in disability attitudes sustained at 3 months.

Assessing patient expectations and concerns in a physical medicine and rehabilitation unit: a real-time snapshot.

INTRODUCTION: To evaluate patient expectations, concerns, and satisfaction during physical medicine and rehabilitation (PM&R) inpatient hospitalization. Patients were also asked to comment on what resources might benefit them during their stay. DESIGN: More than 150 PM&R patients were asked to fill out a self-administered survey in a cross-sectional design. Patients receiving care under 5 other specialties (general medicine, obstetrics and gynecology, general surgery, orthopedics, and neurology) also were surveyed to determine whether qualitative differences existed between PM&R and other departments. In all, more than 1100 patients were given surveys to complete. Patients rated how concerned they were with more than 20 elements of their hospitalization, ranging from quality of food to pain management. Questions were divided into 2 sections: retrospectively before hospitalization and during current admission. SETTING: This study was completed in a large tertiary care PM&R facility with an adjoining medical center in an urban area. PARTICIPANTS: Patients were given the option to complete this survey in an anonymous fashion during their hospital stay. All those who did so were included in this analysis. Six different specialties were represented in the final tally, but the emphasis was on the PM&R department. MAIN OUTCOME MEASUREMENTS: The survey itself included more than 20 questions regarding the details of patients' hospital stays and how concerned they were with them. These categories included plans after discharge, duration of hospitalization, pain management, follow-up of medical issues, cost, insurance, and familiarity with diagnosis, physician, and medications. Other outcomes included patient input into what interventions they thought would most benefit them as well as a global satisfaction rating. RESULTS: Data analysis was performed with SPSS. Tukey tests provided comparison information across specialties. The response rate within PM&R was 68% (n = 128), whereas for all specialties combined it was 54% (n = 606). Multiple factors were found to be significant when examining expectations versus actual admission concerns. Most prominently within PM&R, patients indicated that they were less concerned during their admission than they thought they would be about potential duration of hospitalization (P < .001), understanding of diagnosis (P < .04), follow-up of medical issues (P < .01), and plan of care (P < .001), among others. However, patient expectations in other areas did not change or were negatively affected, such as help at home (P < .05), plans for discharge (P < .001), family involvement at home (P < .01), and future pain management at home (P < .05). Furthermore, qualitative comparisons among other specialties demonstrated differences in many areas. CONCLUSION: Results support the idea that the multidisciplinary approach inherent in PM&R positively alters many patient expectations related to outcomes. This has direct relevance to patient satisfaction and outcomes and warrants further investigation. The authors offer some potential interventions for future improvement in this area.

Implementation of peer review into a physical medicine and rehabilitation program and its effect on professionalism.

OBJECTIVE: To examine the effects of implementing a peer review evaluation system on residents' attitudes and perceptions of professionalism, a core competency of the Accreditation Council for Graduate Medical Education (ACGME), in a Physical Medicine and Rehabilitation (PM&R) program. DESIGN: Four classes of residents were divided prospectively into a control and an intervention group. All residents were asked to complete a survey regarding their attitudes and perceptions on both peer review and professionalism. Only 2 of these classes participated in a newly adopted peer review evaluation system, after which time all participants were again asked to fill out the surveys. SETTING: Residents were from a PM&R residency program at an urban tertiary care medical center. PARTICIPANTS: All residents who completed the entire survey preintervention and postintervention were included. METHODS: The intervention was the introduction of peer review into residents' evaluation assessments. All residents filled out a survey with questions relating to peer review and professionalism before and after this intervention. MAIN OUTCOME MEASUREMENTS: Outcomes include understanding how residents perceive various attributes of professionalism, peer review, and the interconnection of the 2. RESULTS: Data analysis using SPSS was performed using survey scores for 46 residents preintroduction and postintroduction of a peer review evaluation system. Analysis revealed that residents who participated in the peer review process were more likely to agree that certain aspects of daily patient care, behaviors, and concepts were components of professionalism. However, they continued to believe that residents are ultimately not responsible for their colleagues' professionalism and that peer review might be harmful to a residency program. CONCLUSION: This study introduces an interesting dichotomy. Peer review clearly influences resident outlook on professionalism and yet there is a high suspicion regarding its implementation. If appropriately implemented, peer review may be a potent method of enhancing the education of this ACGME requirement.

Exploring systems-based practice in a sample of physical medicine and rehabilitation residency programs.

OBJECTIVE: This study explores physical medicine and rehabilitation (PM&R) residents' attitudes, knowledge, and perception of health care policy in the context of systems-based practice, one of the Accreditation Council for Graduate Medical Education's core competencies for residency training. DESIGN: A cross-sectional, observational design was used via survey administration. These surveys were categorized into 6 different sections: (1) general health care policy; (2) resident awareness of and involvement in policy matters; (3) specific policy pertaining to physical medicine and rehabilitation; (4) rehabilitation alternatives to acute care; (5) documentation; and (6) educational exposure. Residents filled the survey anonymously, noting only their postgraduate year and program name for identification. SETTING: This study was conducted at 3 large PM&R residency programs in Pennsylvania, New Jersey, and New York. PARTICIPANTS: Residents participating in this study totaled 32 from Program A, 26 from Program B, and 18 from Program C. METHODS: Residents at all 3 programs were asked to complete a 34-question survey. In total, 57 surveys were evaluated. The response rates for completing the entire survey for the 3 programs were 81% (26 of 32), 73% (19 of 26), and 67% (12 of 18). The overall response rate was 75%. Not all residents at each program were given surveys to complete. MAIN OUTCOME MEASURES: This study explored resident's attitudes, knowledge, and perception of healthcare policy. Outcomes included understanding how residents feel about the extent of their general policy education, their awareness of current issues and the organizational entities that shape these policies, and whether they should be exposed to these topics within the setting of their training programs. Responses were measured on a 1 (strongly disagree) to 9 (strongly agree) scale. Specific paired t-tests were performed on select questions to further validate the responses. RESULTS: Residents uniformly agree that healthcare policy is an important aspect of medical education and should be taught within their residency programs but do not feel that they currently play an active role in affecting change (8.1 +/- 0.8 vs. 3.4 +/- 1.6, P < .001). They admit to not being aware of how to get involved but would like to delve more into these issues (3.9 +/- 1.5 vs. 7.1 +/- 1.5, P = .01). Pertaining to PM&R-specific policy, residents believe that functional ability trumps diagnosis as the most important determinant for admission to an acute inpatient facility (7.5 +/- 1.2 vs. 5.9 +/- 1.8, P < .001). Although residents see the importance of documentation, they indicate they are not adequately trained in this area (8.2 +/- 0.7 vs. 3.9 +/- 1.1, P = .04). Finally, residents acknowledge they have limited understanding of other rehabilitation delivery options or insurance companies (5.5 +/- 1.2 and 3.5 +/- 1.7). CONCLUSION: Systems-based practice is a core requirement of residency training yet has not been extensively studied. This study suggests that residents find systems-based issues important to their overall education but are not sufficiently or effectively addressed in residency. The healthcare delivery environment including PM&R is rapidly changing. It is imperative that residents are equipped with the knowledge of and ability to adapt to these changes.

Stroke and neurodegenerative disorders: 2. Poststroke medical complications.

OBJECTIVE: This self-directed learning module highlights common poststroke medical complaints encountered on an inpatient rehabilitation unit. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on the differential diagnosis, evaluation and management of chest pain, mental status changes, weight loss and poor motivation in stroke patients. The goal of this article is to expand the learner's knowledge of how to diagnose and manage common medical complications of stroke patients in rehabilitation.