How Does Globalization of the Specialty of Physical Medicine and Rehabilitation Impact U.S. Physiatrists?
Article Outline
- Introduction
- Results of Globalization-Information Sharing
- Results of Globalization-Public Policy
- Conclusions
- References
- Copyright
Introduction
Disability is a major problem throughout the world, both in developing and developed countries [1]. The health conditions that cause or are likely to cause disabilities in the United States exist worldwide [2]. The focus of people with these health conditions is to function in their communities as they choose. Thus, the conditions U.S. physiatrists treat are global, as are their goals of maximizing function.
The number of physicians specializing in physical medicine and rehabilitation (PM&R) internationally is increasing, both in the number of countries where they exist, and the number in each country. The International Society of Physical and Rehabilitation Medicine (ISPRM) lists 39 national PM&R societies as its members [3] as of July 2, 2008. These international physicians are sources of substantial clinical innovations, research findings, and educational programs.
Communication internationally now can be almost instantaneous, both visually and verbally. The availability of e-mail and electronic attachments creates opportunities for highly effective virtual interactions. Web-based techniques can make information readily available at the convenience of the user. International travel has commonly increased the options for face to face discussions.
These 3 elements, the universal existence of conditions causing disability, the existence of PM&R specialists throughout the world, and the use of effective and efficient communication methods, have globalized PM&R. This report addresses how this globalization impacts U.S. physiatrists.
Results of Globalization-Information Sharing
Scholarly Publications
One of the more visible results of the globalization of PM&R is the number of papers with international authors that are published in the Archives of PM&R and the American Journal of PM&R. Multiple observers report close to 50% of their articles are from foreign sources. These articles are mostly scientific, often including randomized clinical trials, but also including commentary regarding international position papers on PM&R, such as the White Book on Physical and Rehabilitation Medicine in Europe [4].
Increasingly, English is the language used by medical journals throughout the world. The editors of these journals wish to expand their readership as widely as possible. Some of their strategies include maximizing their impact factor (a measure of the citations to a journal [5]), becoming the official journal of organizations, and enlisting the input of international associate editors. An effect of these expansion goals will be an increased acceptance of papers from international authors as long as they meet the editorial standards of the journals. This effect will include international journals accepting papers from U.S. authors as well as U.S. journals publishing papers from foreign authors. Thus, a significant number of the journal articles and other materials accessed by U.S. physiatrists are and will continue to be from international sources.
Meetings
The subjects addressed in the programs of international PM&R meetings are very similar to those of our domestic professional meetings. For many years, the program directors of international meetings have supported the travel of selected U.S. experts to present invited lectures. In recent years, the American PM&R professional societies have invited foreign experts to be faculty members at their annual meetings. The scientific program chairs of these meetings have used these international exchanges as a means to provide the most up to date research and clinical innovations to their attendees.
A significant number of international physiatrists attend the meetings of the American Academy of PM&R (AAPM&R) and the Association of Academic Physiatrists (AAP). They do this to access information on the advances in PM&R presented to U.S. physiatrists. Their presence enriches the informal discussions that occur in conjunction with these meetings.
Thus, U.S. physiatrists attending the meetings of their own professional societies increasingly will find physiatrists from other countries as fellow attendees and as faculty participants.
Intellectual Stimulus
Researchers and clinicians interested in advancing evidence-based medicine are stimulated by sharing ideas and observations with others having similar interests. Such sharing occurs through the presentation of papers and face-to-face discussions in addition to publishing articles. The international physiatrists that publish in U.S. journals often present their early developments at the meetings of their own professional societies, where they are also available for informal discussions. To some extent, both U.S. and international physiatrists have traveled to other countries to share in the early development of new techniques or the development of guidelines. The contacts they develop often are reinforced by continued electronic communications. Additional U.S. physiatrists wishing to be involved during the early development phases of some innovations may need to add international meetings and visits to their travel schedules.
Terminology
U.S. physiatrists already can note in the publications and reports of international physiatrists and to some extent those of their colleagues the use of terminology with international origins. For instance, many of the physiatric organizations worldwide refer to the specialty as physical and rehabilitation medicine (PRM) rather than as PM&R. Many speakers and authors, both domestic and international, now use the specific definitions of the International Classification of Functioning, Disability and Health published by the World Health Organization [6]. Among the International Classification of Functioning, Disability and Health definitions are health condition, functioning, disability, activity, participation, environmental factors, and personal factors; some of these definitions are different from the common usage in the United States. For instance, disability is an umbrella term for impairments, activity limitations, or participation restrictions [7]. When observing the use of these terms, U.S. physiatrists now need to consider whether their source intended them to reflect the ICF definitions, or whether they may have been used generically or in the context of an alternative classification.
Organizations
An extensive network of PM&R organizations has contributed to the coordination, communication and collaboration among PM&R specialists internationally, including international, regional, and national societies. The ISPRM is the international professional society primarily of specialists in PM&R. As mentioned previously, it lists 39 national societies of PM&R specialists as its member societies [3]. There also are regional organizations of PM&R specialists, such as the Asian Oceania Society of PRM, the European Society of PRM, and the Latin American Medical Association of Rehabilitation (AMLAR).
The AAPM&R is a member national society of the ISPRM [3]. Through its membership, the AAPM&R has a position on the Board of Governors of the ISPRM (William Micheo, MD). The ISPRM has both national society and individual members. Many AAPM&R members are also individual members of the ISPRM. Individual membership is required to serve as a member of its Executive Committee. The following AAPM&R members are officers and Executive Committee Members of the ISPRM: Joel DeLisa, MD (President), Martin Grabois, MD (Treasurer), Walter Frontera, MD (Regional Vice-President of North America), and Mark Young, MD (Representative of Active Individual Members). U.S. physiatrists through the AAPM&R are able to influence the policies and activities of the ISPRM.
The ISPRM has a website (www.isprm.org) that includes extensive information about its organization and activities. Much of the website has open access. Those who are interested can review the ISPRM monthly publication, News and Views, on the website. In addition to general articles on international subjects, these publications include listings of international meetings of potential interest to physiatrists. The ISPRM has an International Exchange Committee that has been active in facilitating the placement of U.S. students and physicians into short-term overseas experiences and the placement of international physicians into U.S. clinical observerships and research fellowships. Its Education Committee has been active in placing educational materials on its website, although many of these may be accessed only by those with individual memberships.
Results of Globalization-Public Policy
Service Delivery Models
All countries seem to be concerned about the effective use of the relatively limited resources available for medical care and social services. The paucity of rigorous studies on the cost effectiveness of rehabilitation treatments and programs makes them vulnerable to governmental cutbacks. Just as in the United States, physiatrists internationally support the need for cost effectiveness studies to document the need of their services. The variations among countries in how rehabilitation services are organized provide an opportunity to study important elements of services without disrupting the standard of care in any one country. There are few such studies to date; an example is a comparison of physical therapy services in New Zealand and the United States [8]. The increase in communication among international physiatrists and the universal problems they face should facilitate such comparative studies in the future.
U.S. physiatrists are witnessing alterations in the models of rehabilitation with which they are familiar. For instance, there have been changes in the number of rehabilitation beds and the mix of patients admitted to rehabilitation hospitals since the recent CMS initiatives using more stringent medical necessity criteria [9]. International models of inpatient rehabilitation are closer to the skilled nursing home intensities seen in the United States. These international models could potentially be used to justify reductions in the treatment intensities of U.S. programs unless comparative studies show enhanced results from the U.S. approaches. Either way, U.S. models of care are likely to be influenced by international ones.
Conclusions
Like other social issues, the management of those with or likely to have disabilities has acquired many of the characteristics of globalization. This globalization of PM&R has resulted in changes in the experiences of U.S. physiatrists, and is likely to result in further changes in the future. If U.S. physiatrists are to influence the forces that form their practice environments, they or their representatives will need to participate in the international activities that contribute to these forces.
References
- . Enable: rights and dignity of persons with disabilities (Factsheet on persons with disabilities). http://www.un.org/disabilities/default.asp?id=18Accessed July 14, 2008.
- . Health statistics and health information systems (The global burden of disease: 2004 update). http://www.who.int/healthinfo/global_burden_disease/2004_reort_update/en/index.html2008;Accessed November 9, 2008.
- . http://www.isprm.orgAccessed November 9, 2008.
- . Rehabilitation is growing in Europe: A particular role for ESPRM. Am J Phys Med Rehabil. 2008;87:596–600
- . Impact Factors: Use and Abuse. Perspectives in Publishing. http://www.elsevier.com/framework_editors/pdfs/Perspectives1.pdf
- . International classification of functioning, disability and health: ICF. Geneva: WHO; 2001;
- . International classification of functioning, disability and health: ICF. In: Geneva: WHO; 2001;p. 3
- . A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities. Arch Phys Med Rehabil. 2005;86(12 Suppl 2):S115–S120
- Inpatient rehabilitation facility PPS and the 75 percent rule. [Centers for Medicare & Medicaid Services Website]. June 8, 2007. http://www.cms.hhs.gov/InpatientRehabFacPPS/Downloads/IRF_PPS_75_percent_Rule_060807.pdfAccessed November 9, 2008.
- † Disclosure: nothing to disclose
Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org
PII: S1934-1482(08)00036-1
doi:10.1016/j.pmrj.2008.11.009
© 2009 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
