Maintaining Health, Wellness, and Fitness: A New Niche For Physiatry?

Weinstein, Stuart M.

doi:10.1016/j.pmrj.2009.08.451

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Volume 1, Issue 9 , Pages 793-794, September 2009

Maintaining Health, Wellness, and Fitness: A New Niche For Physiatry?

University of Washington, Harborview Medical Center, 325 Ninth Ave., Box 359721, Seattle, WA 98104^†

In 1996, a physical medicine and rehabilitation manpower study concluded that the overall demand for physiatrists would likely exceed supply through the year 2015 [1]. A revised supply and demand projection for physiatry through the first quartile of the 21^st century [2] mostly supported that original study, identifying several potential modifying factors including an alteration in the rate of training of physiatrists in the United States; the impact of health care reform (then managed care; now the 2009 iteration); and the state of public awareness of physiatry. Regarding this latter factor, the original study in fact stated, “If the profession is successful in informing the market regarding the advantages of physiatry, the profession can continue to grow without experiencing excess supply, in the aggregate, for the foreseeable future.” These two reports served as the basis for the American Academy of Physical Medicine and Rehabilitation (AAPM&R) to direct resources to a long-term marketing campaign for the specialty and its constituency.

But understanding and appreciating the maximal value of physiatry to individuals and to society as a whole has been a moving target. From 1950 until 1980, physiatry was known primarily in the context of classical inpatient neurorehabilitation. Beginning in the mid-1980s, the emphasis moved toward outpatient management of musculoskeletal (MSK) disorders. And in the past decade, physiatry has made its mark in interventional pain medicine. As a specialty, physiatry has demonstrated, in these successive eras, the ability to be dynamic in responding to patient/consumer demands and needs: first providing the skills necessary to address the needs of the war-injured; next emphasizing diagnostic and therapeutic acumen in the treatment of what are primarily nonsurgical problems (ie, MSK disorders); and finally combining knowledge of functional anatomy and physiology with technology to provide minimally invasive therapeutic procedures.

However great the value of physiatry has been over these several decades, competition with other medical specialties (neurology [neurorehabilitation], primary care and orthopedics [MSK medicine], and anesthesiology and radiology [pain medicine/interventions]) will certainly tilt the supply/demand ratio toward an excess of physiatrists. Therefore, it behooves physiatrists to continue to identify a niche that both maximizes service value and is not yet saturated by other specialties. Further, it should be an area that is vastly researchable and that lends itself to performance measures. And finally, it should be a field that is applicable to any physiatrist. So what is this niche area? Maintaining health and vitality through prevention and wellness/fitness training.

Historically, physiatrists have established themselves as experts in treating the secondary impairments associated with many types of neurological, musculoskeletal, cardiovascular, and other injuries and diseases. Certainly, many physiatrists prescribe rehabilitative exercises for their functionally impaired patients. It seems a natural transition to apply that knowledge and skill toward emphasizing wellness and fitness in able bodied persons as well as persons with disabilities. AAPM&R has tacitly acknowledged the importance of associating the specialty with this concept as evidenced by its support of the combined American College of Sports Medicine/American Medical Association initiative, Exercise is Medicine [3], and as a participating member of the US Bone and Joint Decade initiative [4]. Yet for many individual physiatrists, assessing inactive but otherwise “healthy” people for the purposes of prescribing a comprehensive exercise program is not familiar territory. This idea is further explored by Edward Laskowski, MD, who has offered an Invited Perspective relating to this topic in this issue of PM&R [5]. Dr Laskowski is a physiatrist, professor at the Mayo Clinic College of Medicine, co-director of the Mayo Clinic Sports Medicine Center, former member of the President's Council on Physical Fitness and Sports, and has a strong interest in research and a clinical interest in fitness training. I am sure that you will find his thoughts about the role of physiatrists in the management of obesity and inactivity thought provoking.

It has been long been my contention that while physiatrists are very fluent in the area of rehabilitating patients from injury or disease, they are (as a whole) inexperienced and unprepared to design training programs for fitness and vitality. In general, physiatrists (for that matter, most clinicians) are well trained for identifying and treating pathology, but often have just a cursory understanding of exercise physiology and fitness. In order for physiatrists to gain the fund of knowledge necessary to develop this expertise, this is an area that will require a dedicated curriculum. And for many reasons this makes sense: exercise prescriptions are already part of the physiatry culture; promoting exercise enhances a healthy society; physiatrists can develop a niche area of maintenance that is not yet monopolized; health maintenance and maintenance may fit nicely with the concept of value-based reimbursement; and this may just turn out to be a great new marketing strategy.

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References

Hogan PF, Dobson A, Haynie B, et al. Physical medicine and rehabilitation workforce study: the supply of and demand for physiatrists. Arch Phys Med Rehabil. 1996;77:95–99

Hogan PF, Dobson A, Hughes J, et al. Supply of and demand for physiatrists: review and update of the 1995 physical medicine and rehabilitation workforce study (A special report. The Lewin Group). Am J Phys Med Rehabil. 1999;78:477–485