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Physiatry: The Medical Rehabilitation Specialty
By Miki Fairley Physical medicine and rehabilitation (PM&R) "is
often called the 'quality-of-life' profession because its aim is to
restore optimal patient functioning. The focus is not on one part
of the body, but instead on the development of a comprehensive
program for putting the pieces of a person's life back
together--medically, socially, emotionally, and vocationally--after
injury or disease."--the American Academy of Physical Medicine
& Rehabilitation (AAPM&R)
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Charles Levy, MD |
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Physical medicine and rehabilitation (PM&R)
"focuses on how the whole person functions," says Charles
Levy, MD, chief, Physical Medicine & Rehabilitation
Service, North Florida/South Georgia Veterans Health System,
Gainesville, Florida. "Each specialist on the rehab team has his
perspective, but we physiatrists have the responsibility of seeing
the entire picture--that's part of our training." The
"whole-patient" view encompasses treatment or referral for medical
conditions, pain management, making sure the patient receives
needed physical or occupational therapy, and prosthetic or orthotic
devices and training in their use, Levy explains. Often
psychological, vocational, and funding issues also must be
addressed.
"We try to make sure that everything patients need to get on
with their lives--not just heal their wounds--is in place," says
Clay Kelly, MD, director, Amputee Clinic,
MetroHealth System, Cleveland, Ohio.
Team Model
Physiatry emphasizes the team model, with the physiatrist as the
leader, coordinating treatment. The physiatrist is charged with
overseeing the process and assuring that the other team members are
working in concordance. This is similar to putting the pieces of a
puzzle together.
"A major theory of physical medicine is that the patient is
managed by a team--we're not alone," says Kelly.
Ideally, key members of the team will see the patient together
and develop a treatment plan. If consultation is needed to reach
consensus, the team may adjourn to a separate room for discussion,
then return to the patient.
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Clay Kelly, MD |
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The patient thus benefits from the best thinking
of several professionals who can interact with one another and the
patient on the spot. Besides physiatrists, teams may include
orthotists/prosthetists, physical or occupational therapists,
orthopedists, rehabilitation nurses, residents, and others.
Harry Webster, MD, Pediatric Division chief,
New England Medical Center Department of Physical Medicine &
Rehabilitation, Boston, Massachusetts, points out that the patient
"gets the best of our thinking," when the team meets together at
the same time. "I don't consider myself the ultimate authority; I'm
looking for that synthesis to give the patient the best
prescription. That doesn't happen if I write the prescription and
two weeks later, the patient and family go to an orthotist I've
never seen."
The physiatrist takes the lead in evaluating symptoms and making
appropriate diagnoses. The rest of the team then knows the medical
issues and can also anticipate medical complications that could
interfere with rehab. However, the physiatrist also needs to listen
closely to other team members, since they have in-depth experience
in their specialties and can contribute information to help the
physician make good decisions, says Walter Davis,
MD, director of education, Center for Biomedical Ethics,
Department of Physical Medicine & Rehabilitation, University of
Virginia, Richmond.
"This is not the typical medical model, in which the doctor
takes the history of the patient, performs an examination, makes a
diagnosis, and prescribes treatments," explains Davis. "The rehab
model is more complicated; the physician should be checking in with
members of the rehab team to get their experience and
thoughts."
The patient also enjoys the convenience of "one-stop
shopping."
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Walter Davis, MD |
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"When an orthotist comes to our clinic, we provide
a service to families that is outstanding," says Webster. "Not only
can we do the casting on that same visit, thus saving the family
time, parking expenses, etc., but we can put our heads together for
the best solution and appliance for that patient."
"Patients don't like having to see the doctor, then wait to see
the prosthetist, then wait again to see the physical therapist,"
says Davis. "When patients come to our clinic and we see them
together, they feel they've gotten the best interaction from the
clinical team--a meeting of the minds, rather than three different
people saying three different things."
Vikki Stefans, MD, associate professor, University of Arkansas
for Medical Sciences Department of Pediatrics and Physical Medicine
& Rehabilitation, Little Rock, often coordinates overall
medical care for inpatients, rather like a primary care physician.
However, the primary care physician generally coordinates
outpatient care, while she works with him/her on
rehabilitation-related treatment and makes appropriate referrals
for O&P care.
Stefans appreciates the team approach: "By working together, we
can come up with a plan. One might think of something the others
didn't."
Webster gives much credit to his pediatric patients' families as
vital team members: "They are really doing the everyday work to
help these children achieve their maximum potential. We are
privileged to help them; we try to do this by achieving the best
coordination and service possible."
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Vikki Stefans, MD |
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Academic medical centers are usually necessary for
a true team approach, notes Davis. Reimbursement issues and simple
logistics make it much more difficult for physiatrists with
separate, independent practices to utilize a true team approach,
which is a hallmark of what makes the PM&R specialty unique, he
explains.
"The team approach is also alive and well in the Veterans Health
System," adds Levy.
Many physiatrists in private practice focus on sports medicine
and pain disorders such as back pain, rather than treating
amputations, stroke, cerebral palsy and other largely pediatric
conditions, and brain and spinal cord injuries, Webster notes.
"They are generally procedure-oriented, using interventions such as
steroid injections; then sending the patient to a therapist in
another facility. It is a challenge to do a true team
approach."
Pain Management
Pain management is a vital part of the physiatrist's
responsibility. "If pain is not being controlled, the rest of the
rehab doesn't go anywhere," says Davis. For example, when the
physician sees the patient in his morning rounds, he may not gain
accurate information on how well pain medicines are working.
However, by working with the patient later in the day, the
therapist can note problems and report them to the physician. For
instance, the patient may still be in too much pain for effective
therapy or be so over-medicated that he or she is practically
asleep.
Orthotists/Prosthetists
What do physiatrists look for in
orthotist/prosthetist team members?
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Clay M. Kelly, MD,; Sharon L. Kelly, CP; Joyce Acord, LPT, instructing John Lee, MD, a PM&R resident at MetroHealth |
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"Someone who likes being part of a team and coming
up with solutions together," answers Stefans. Being willing to be
flexible and modify a brace or prosthesis to meet a particular
patient's or family's needs is vital too, she adds, citing an
example of a brace that was simply too stiff for the family to put
on the child. The orthotist modified the brace to make it more
pliable and easier to don and wear.
Kelly, who specializes in amputee care, looks for a prosthetist
who is talented, ethical, and up-to-date, since technology is
advancing rapidly. "Fitting a prosthesis is an ongoing dynamic
process," he explains. "I tell patients that, due to adjustments
and follow-up, they'll see the prosthetist more often than they
will me. Prosthetists really need to pay attention to patient
satisfaction," he adds.
When possible, Levy likes to have orthotists/prosthetists from
about three different companies as part of the team evaluating the
patient. He sees several advantages to this procedure:
1) it's educational, since the
orthotists/prosthetists learn more about medical and
physical-therapy related considerations, and physicians and other
specialists learn more about prosthetics and orthotics;
2) the device recommendations and reimbursement
required are community standards and not "overblown;" and
3) in this setting, the prosthetists/orthotists
often are more willing to share thinking to come up with good
solutions, even if they are competitors.
Surgeons and Rehab
Noting that MetroHealth operates one of the largest and busiest
trauma centers in the country, Kelly says that the team approach is
being used more often for amputations. "More surgeons are beginning
to understand that a beautiful residual limb is a work of art and
makes everything down the line easier for the amputee to regain
function." Surgeons and PM&R physicians have a complementary
relationship at MetroHealth, with the orthopedic, vascular, and
plastic surgeons sending Kelly practically all their amputee
patients once the patients are past the acute phase. "However, that
is not true in all places," he adds. "Sometimes the orthopedists
want their residents to have experience with amputees."
Some surgeons are open to input from the rehab team and some are
not, says Davis. "Some--and I work with one like this--will
actually involve the rehab team before surgery. This is a great
idea, but often underutilized. It's what we should aim for in
amputee rehabilitation: to have input from the whole team--surgeon,
physiatrist, prosthetist, physical therapist, and nurses. This is
time-consuming, but provides the best patient care. It's not
simple, but it's worth tenfold to the patient."
Stefans says that she often coordinates care after surgery and
sometimes helps in preparation for surgery, especially if surgery
will change the patient's function. "Orthopedic and functional
goals may be different or may coordinate exactly." However, if the
orthopedist is concerned about fracture healing, wound protection,
and similar issues, "we don't want to interfere with that in any
way."
Orthopedic surgeons are often responsive to the need to prepare
the limb for a prosthesis, since by the nature of their work they
are more oriented toward function, it was noted. "They are more
likely to see success as a more functional person, rather than a
well-healed residual limb," says Davis.
However, vascular surgeons often look only at the limb, with the
goal to salvage it or at least save as much tissue as possible, he
said. "The goal is to cut as little as possible to get to where
there is circulation. But if the goal is simply to save a limb and
function is not considered, it's doomed."
He cites partial foot amputations as an example: "The patient
may never be able to walk on that foot, due to pain and skin
breakdown." A higher-level amputation in the beginning may obviate
the need for later amputations and get the patient mobile right
away, he explains. "If the patient can't walk right away, he may
suffer contractures, deconditioning, depression over spending time
in a wheelchair and wondering if later surgery will be needed, plus
the risk, expense, and stress of later surgeries if they are
needed. "Sometimes it's better for the patient to undergo a
higher-level amputation, go through the grieving process, and get
on with life," he says. His comments point out a sound reason for
bringing the rehab team into the amputation process early.
The physiatrists concur that overall, amputation surgery is
improving and is being given more consideration than in the past.
One physiatrist recalls that as a senior medical student, he was
asked to do an amputation. "At the time, I was excited to have the
opportunity. But in retrospect, I was shocked. They obviously
didn't take it very seriously." Amputees are no doubt glad that
times are changing!
Why Did They Choose Physiatry?
Orthotists and prosthetists interviewed by The O&P EDGE
commented on how much they appreciate the time physiatrists spend
with their patients. Physiatrists earn kudos for their dedication,
even though they may take a hit financially, since a doctor who
sees four patients in an hour will receive more remuneration than a
doctor who sees only one amputee in that same hour, but addresses
the multiple dimensions of care.
What draws physicians to this
specialty?
Sometimes it's a longstanding interest in the field. Kelly has
had an interest in amputee care since he was young, and he is even
married to a prosthetist: Sharon Kelly, CP, who works for Hanger
Prosthetics & Orthotics, Euclid, Ohio. Kelly says he would be
delighted if their three sons follow their parents into a medically
related field, "but that's up to them."
Working with children with disabilities and special needs in a
summer camp as a volunteer hooked Stefans into deciding on a career
as a pediatric physiatrist.
When Davis was in medical school, he attended a yearly medical
student association conference in Washington, DC. Among the
exhibits was one from the Walter Reed Hospital rehabilitation
physicians. "Before that, I didn't realize this was a separate
specialty," he remembers. Davis had already had experience in
working with disabled children and adults before entering medical
school, and PM&R "enables me to combine medicine with my
interest in working with disability."
Levy's first interest was in neurology, but PM&R was more
appealing. In some aspects of medicine, once the diagnosis is made,
the recipe for care is basically always the same, Levy notes. "But
with physical medicine and rehabilitation, you have to look at the
whole person. You can't get the answers out of a book." For
example, to help one person psychologically through rehab, the
physiatrist might have to be a cheerleader, for another patient,
being a sympathetic listener might be best. Some benefit from
support groups or joining an online listserv, others don't want to
talk about their problems. Some are motivated by their desire to
return to work or accomplish some skill. "You have to understand
that person and what helps him get up and what knocks him down,"
says Levy. Matching the person to the solution also extends to such
practical matters as prosthetic component selection: for instance,
an extremely active patient needs a rugged prosthesis, while
another patient may be a milder user.
Describing the specialty's appeal, which likely applies to many
other PM&R physicians, Levy says, "In rehabilitation, you
almost always can improve patients' lives in some way, even if they
are not totally restored. I like to be able to think creatively and
come up with solutions."
Physiatry: Focusing on Function
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Photo courtesy of Vikki Stefans, MD, pediatric physiatrist at UAMS and Arkansas Children’s Hospital. |
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Physiatrists focus on restoring function, notes
the American Academy of Physical Medicine & Rehabilitation
(AAPM&R). Physiatry is one of the 24 medical specialties
certified by the American Board of Medical Specialties. Currently
there are 80 accredited residency programs in the US and more than
6,700 practicing physiatrists.
Although physical means of healing have been practiced for
thousands of years, PM&R began in earnest in the 1930s with the
physical treatment of musculoskeletal and neurological conditions.
The field broadened its scope after World War II when thousands of
veterans returned home with catastrophic injuries. In 1947, the
Advisory Board of Medical Specialties recognized physiatry as a
medical specialty.
Physiatrists treat a broad range of conditions, including acute
and chronic pain and musculoskeletal disorders. They coordinate
long-term rehabilitation for patients with spinal cord injuries,
cancer, stroke and other neurological disorders, brain injuries,
multiple
sclerosis, and amputations. Physiatrists treat about 50,000 new
amputees each year, according to AAPM&R.
Physiatrists practice in rehabilitation centers, hospitals, and
private offices. Often they have broad
practices, but some concentrate on one area, such as pediatrics,
sports medicine, geriatric medicine, or brain injury. In recent
years, the field has seen an increased focus on musculoskeletal and
industrial medicine, pain management, sports medicine, and
electromyography.
For more information, visit the American Academy of Physical
Medicine & Rehabilitation, www.aapmr.org, and the Association of Academic
Physiatrists, www.physiatry.org.
Watch for an article on physiatrists from the
prosthetist/orthotist perspective in an upcoming issue. 
Table Of Contents - May 2003
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