Subspecialization Training in PM&R
Article Outline
Subspecialization has become progressively more prevalent throughout all of organized medicine as physicians have chosen to focus their areas of practice. The reasons for this are multiple and beyond the scope of this discussion, which will be limited to the trend toward formal subspecialization in physiatry.
It is virtually impossible to obtain verifiable data concerning the exact number of physiatrists that consider themselves subspecialists or the number of physiatrists with formal training in their particular area of subspecialization. However, there is evidence that approximately 50% of the current graduates of all physical medicine and rehabilitation (PM&R) residency training programs are seeking further subspecialty training rather than directly entering active practice. The most accurate data source to quantify this assumption comes from the American Board of PM&R (ABPMR) (personal communication, American Board of PM&R, 2009).
In 2007, 380 physicians completed PM&R residency training. Of these physicians, 294 subsequently took the 2008 Part II Examination. A total of 149 (50.7%) reported being in fellowship (subspecialty or advanced) training. Similarly, in 2008, 376 physicians completed training and 313 took the 2009 Part II examination. Of these physicians, 146 (46.6%) reported being in fellowship training (personal communication, American Board of PM&R, 2009).
Fellowship Positions
Formal subspecialization training falls into 2 broad categories: those accredited by the Accreditation Council for Graduate Medical Education (ACGME) and those not. Each pathway has some distinct advantages and disadvantages both for the trainee and the program.
The ACGME-accredited fellowships are subject to the ACGME guidelines. There is a set of program requirements that is completely vetted by the entirety of organized medicine. There is also a formal review of the fellowship program by ACGME to assure compliance with subspecialty program requirements. ACGME-accredited fellowships are usually administered through an academic program. The fellow is considered a resident (a PGY5 in a 4-year program such as PM&R); thus, salaries and work hours both within and outside the fellowship are regulated. Graduation from these ACGME-accredited fellowships is typically accepted by privileging bodies as evidence of proficiency in an area of subspecialization.
Nonaccredited fellowship programs may or may not be established within an academic department. These individualized programs have the flexibility to be more tailored to specific areas of practice. They have the luxury to change rapidly as practice patterns change and new medical procedures emerge. Funding sources for the fellows are not regulated and more creative sources of funding can be used. Some, but not all, of these fellowships are readily recognized by privileging bodies.
In the 2007 cohort described previously, 67 of 149 fellows (45%) were working in accredited programs. In the 2008 cohort, the number in accredited programs was 79 of 146 (54.1%). These limited data only serve to indicate both routes are frequently used and must be considered in the ongoing discussion of subspecialty training within PM&R.
Stakeholders
There are a number of stakeholders concerned with subspecialty training, all with varied and some with conflicting interests. All must be recognized in the discussion regarding the future of fellowship training. These stakeholders include: the physiatrists (both fellowship-trained and established practitioners); the training programs (both ACGME-accredited and nonaccredited); the credentialing and certifying bodies (ACGME, American Board of Medical Specialties [ABMS], and ABPMR); the various licensing and privileging bodies; and the “public” (patients, government, and private insurance institutions).
Physiatrists as stakeholders generally fall into one of 2 groups: fellows or established practitioners. The fellows desire a training program that provides superb education in an area of practice, preparing them for independent subspecialty practice. They want their training to be recognized by all privileging bodies and they want the process to be affordable. The established practitioners have multiple issues, differing for each practitioner. However, one overriding issue is to not lose access to, or to be excluded from, areas of physiatric practice as subspecialty training is developed and potentially becomes the gold standard defining competency.
Training programs and their sponsoring institutions need to strike a balance between providing high-quality educational opportunities and their inherent cost. This is true whether the program is ACGME-accredited or not. The varied interests of ACGME, ABMS, and ABPMR influence accredited training programs and the subsequent certification process. These revolve around specific areas of practice, establishing training requirements, initial certification, maintaining certification, and evolving changes in practice within the area of subspecialization. Also involved are the various specialty organizations and additional certifying boards that have interests in the specific areas of physiatric practice that are part of subspecialty training.
Then there are the various licensing and privileging entities that would like to use the training and certifying process to assure competency in those physiatrists participating in their various practice situations. Further, the public stakeholders must be acknowledged. These include the general public (patients) as well as various governmental and private organizations, including payers. However, their desire is universal. They want assurance that the fellowship-trained physician is competent in the area of subspecialization throughout his or her practice lifespan.
Finally, all of these interests must be balanced in some way with other medical/surgical specialty organizations outside of physiatry that share common areas of subspecialty training and practice.
Trends
As all of these factors are considered, 2 additional areas of concern seem to override many of the potential directions that physiatric fellowship training may take. These 2 areas are the number of practitioners that will ultimately be interested in the area of subspecialization and the cost of bringing a subspecialty training and certifying program to fruition.
It is becoming more apparent from multiple sources that the public and the licensing/privileging bodies will require a stringent process of training, initial demonstration of competency, and ongoing monitored evidence of life-long maintenance of proficiency. This will mean an end to the current prevalent process of undergoing training, taking a single certifying examination, and being considered a subspecialist for as long as one is in practice. This process certainly will require ongoing costs for implementation and maintenance.
There has been a dramatic shift over the past decade in the approach to subspecialization by many ABMS boards and ACGME. Previously, each specialty had a separate subspecialty training program. Now there are multiple subspecialty training programs that are shared among specialties, accepting fellows from multiple ACGME-approved residency-training pathways. For physiatrists, these subspecialty programs include pain medicine, sports medicine, spinal cord injury medicine, hospice and palliative care, and neuromuscular medicine. One of the practical reasons for this cooperation is assuring a sufficient number of test takers for validity of the written examination because the number of subspecialists in any one specialty may be too small.
As any certifying body begins to develop a new subspecialty program, it must consider how it will provide for ongoing demonstration of life-long competency in the areas of subspecialization. It has already been an expensive undertaking for diplomates to maintain primary certification; it will certainly be an additional cost for those that seek subspecialty certification in the future.
Personal Perspective
Without doubt, my experiences with ABPMR, the Residency Review Committee for PM&R, ACGME, and more recently the ABMS Committee on Certification, Subcertification, and Recertification, have biased my outlook regarding further subspecialization. However, they also lend me a unique ability to look at physiatry from a broader perspective as to what might be best for this specialty and also acceptable to all segments of organized medicine.
The statistics from ABPMR (see previous section) undeniably demonstrate that a major percentage of physiatrists go on to fellowship training after finishing residency training. More physiatrists are limiting the scope of their practices whether they do subspecialty training or not. Logic dictates to me that fellowship training, along with formalized continuance of competency programs, would ensure better quality of care for the patients that physiatrists treat, which after all is the primary goal.
As of today, it is my opinion that pursuing this formalized fellowship training best meets the needs of our specialty. I did not always subscribe to that point of view. A decade ago, I was convinced, as were many other leaders of the specialty, that subspecialization would dilute the value of the initial certification and lead to a loss of practice opportunities for established nonsubspecialty-trained physiatrists. As I can best determine, that has not occurred; established practitioners continue to have the choice to develop and limit their practices in narrow areas without difficulty. The field continues to be strong and the initial certification continues to hold value. If there has been an adverse consequence, we have lost opportunities to support our diplomates by not joining with other specialties. Sports medicine may be the best example. About 10 years ago, ABPMR declined the opportunity to join with the 4 specialties that started the subspecialty of sports medicine. Physiatrists continued to focus their practice in sports, albeit with some challenges in being unquestionably accepted in all arenas as sports medicine physicians. Fast-forward to present and we have now joined the others in sponsoring the subspecialty, and our diplomates can gain the formal recognition they felt they already deserved.
There is no easy solution concerning subspecialty training in PM&R that will satisfy all the various stakeholders. However, it is necessary that some workable compromises be made to meet the demand of graduating residents for fellowship training. I advocate that we continue to work through the structure of ABPMR and consequently ABMS and ACGME. Without question, this process is complex and at times unwieldy, but the ultimate value is that any subspecialty that is approved by ABPMR has immediate recognition throughout all of organized medicine. Additionally, the structure assures that every subspecialty training program has an organized curriculum with appropriate outcomes and that there will be a formal continuance of competency program.
Although ABPMR may be the lead organization in this process, it should not and cannot go it alone. There needs to be close cooperation between ABPMR, the American Academy of Physical Medicine and Rehabilitation (AAPMR), and other professional organizations that make up this specialty. This was exemplified in the combined effort of ABPMR and AAPMR (including the pediatric rehabilitation special interest group) and the then loose confederation of pediatric training directors that worked together to define and then bring to completion the accreditation of the subspecialty of pediatric rehabilitation medicine. This subspecialty is the only one available solely to physiatrists.
This cooperative pathway of involving all physiatric organizations was similarly instrumental in developing the pain medicine, spinal cord injury medicine, hospice and palliative care medicine, neuromuscular medicine, and, most recently, sports medicine accredited fellowships. The key to success in these 5 subspecialties has been a sufficient number of physiatrists or other practitioners to make their development sustainable both from a test validity and affordability standpoint. Over the past several years, there has been a similar effort considered by ABPMR and potentially other specialties in the area of brain injury. Again, AAPMR has been an integral in defining the practice area and the physiatric practitioners' interest.
In my opinion, the time may now be appropriate to consider another area of subspecialty training for physiatry, namely musculoskeletal medicine. There are large numbers of physiatrists, including interventionalists, that focus their practice in musculoskeletal medicine. The pain medicine and sports medicine subspecialty pathways are available to them, but neither exactly captures the practice focus for many of these physicians. Additionally, there appears to be a greater cooperative interest among specialties than has been present in recent years. This could result in a subspecialty lead by physiatry, but open to multiple specialties as we have seen in pain medicine and sports medicine.
Unfortunately, this formal approach of accreditation is not applicable to every practice area; many are too small to allow the creation of separate, sustainable subspecialty training areas. The American Board of Internal Medicine (ABIM) has proposed an interesting alternative that may be a practical solution. ABIM introduced the concept of focusing all Maintenance of Certification activity in a single practice area. At the completion of the Maintenance of Certification cycle, the diplomate then receives a new specialty certificate that indicates special expertise in that focused practice area. This concept holds great promise for a small specialty such as physiatry with many smaller areas of focused practice.
In summary, certain guiding principles would seem appropriate to assure the best outcomes for the fellowship trainees.
- † Disclosure: 9, Board of Directors ABPMR, member RRC for PM&R, committee member COCERT/ABMS, Board of Directors ECRMG
Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org
PII: S1934-1482(09)01327-6
doi:10.1016/j.pmrj.2009.09.003
© 2009 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
