PM&R
Volume 1, Issue 12 , Pages 1055-1057, December 2009

Pediatric Rehabilitation Medicine Subspecialty Training

  • Margaret A. Turk, MD

      Affiliations

    • Department of Physical Medicine & Rehabilitation and Pediatrics, SUNY Upstate Medical University, Dept of PM&R, JH 311, 750 East Adams Street, Syracuse, NY 13210†
    • Corresponding Author InformationAddress correspondence to M.A.T.
    • ,
  • Jacob A. Neufeld, MD, MSPH

      Affiliations

    • Children's Hospital & Research Center Oakland, Department of Pediatric Rehabilitation, Oakland, CA‡

Article Outline

 

The population of children with disabilities has increased dramatically during the past 40 years, with the greatest increase (from <2% to 7% of those reporting a disability in a national database) occurring in the last 15 years [1]. The number of adults with childhood-onset disabilities also has increased, with an estimated 500,000 each year reaching age 18 years [2] and therefore transitioning into adult health-care services. With one-third of the world's population defined as children [3], it is expected that the number of these patients will continue to increase. Consequently, the health and rehabilitation care for children and adults with childhood-onset disabilities must continue to be an important part of physical medicine and rehabilitation (PM&R) training.

Pediatric rehabilitation medicine (PRM) is a subspecialty within the field of PM&R that provides rehabilitation medicine management for children with physical and cognitive impairments. PRM, one of the oldest subspecialties within PM&R, became a board-certified subspecialty in 1999, with the first examination given in 2003. The growth of the subspecialty is directly linked to the advancements of medical science and improvements in medical care. PRM includes the full spectrum of the PM&R specialty but with emphasis on pediatric specific diagnoses, and the influence of growth and development on medical and rehabilitation goals and interventions.

Besides the typical pediatric diagnoses and conditions anticipated with younger age groups (eg, cerebral palsy, spina bifida, genetic disorders, congenital myopathies), pediatric physiatrists manage children and adolescents with traumatic brain injury, spinal cord injury, amputations, or chronic pain typically encountered by the adult physiatrist. The knowledge of new onset, evolving, and lifelong disabilities and the enabling/disabling process gained from general PM&R enhances pediatric physiatrists' abilities to manage children with disabilities through a lifetime.

There are 2 pathways to enter the subspecialty training for PRM. For those who have completed the general PM&R residency training program, an additional 2 years are required. Those trained through the combined programs (see the section “Combined Training Program”) are required to complete an additional year of fellowship. Either pathway requires 6 years of training in total. Although more common before 2000, there are also physiatrists who have completed training separately in pediatrics and PM&R, totaling 6 years of training; fellowship would now be required for PRM certification.

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Training Within General PM&R Residencies 

Since 1967, all current trainees participate in some element of pediatric rehabilitation during the required experience within a general PM&R residency training program; before this, there were no requirements for training in pediatric rehabilitation. These requirements have also changed over time, with the most recent PM&R Residency Review Committee program requirements defining content but not time commitments [4]. The program requirements also identify knowledge requirements about aging with a disability, which should include issues of lifelong disability, including those of adults with childhood-onset disabilities. Consequently, the experience for residents differs significantly among training programs, which was identified in a survey of programs reported in 2002 [5].

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Combined Training Program 

The American Board of Physical Medicine and Rehabilitation (ABPMR) and the American Board of Pediatrics (ABP) developed a combined training program beginning in 1988. These residency training programs require early commitment to a career in pediatric physiatry and consist of 5 years (60 months) of training: the 36-month pediatric training requirement is met with 30 months of pediatric plus credit for 6 months of pediatric-related PM&R training; the 36-month PM&R training requirement is met by 30 months of PM&R training plus credit for 6 months of PM&R-related pediatric training. These programs are defined by an agreement between the ABPM&R and the ABP. The first year of training must be through the pediatrics residency, and residents can declare a combined training experience at the time of the National Resident Matching Program or some time within the PGY 1 training year, but not later. Programs must obtain written permission from both the ABPM&R and ABP to offer this training. This pathway grew to a maximum of 17 programs in the mid-1990s, followed by a significant decrease thereafter. This trend coincides with changes in federal support for graduate medical education (GME). Presently there are 7 combined training programs available nationally with 18 trainees enrolled [6]. Graduates of the programs in the mid-1990s who responded to an ABPMR survey reported the need for further integration of pediatric and rehabilitation training [7].

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PRM Fellowship Programs 

Advanced training in pediatric rehabilitation has been present since the early formation of board certification in PM&R. Fellowship programs began as early as the 1950s, with an influx in the 1970s. These fellowship programs developed initially as apprenticeships, often dependent on single individuals with expertise, had no common curricula or requirements, and were not self-sustaining. However, since the advent of PRM acceptance as a subspecialty by the American Board of Medical Specialties in 1999, and the approval of requirements for fellowship training by American Council on Graduate Medical Education (ACGME) in 2002, there are now 15 accredited fellowship programs [6], with more similar organization and a common curriculum and evaluation process.

The ACGME fellowship requirements are now under review and are typically reviewed every 5 years. They are available on the ACGME website, under PM&R RRC. The PRM Fellowship Program Directors maintain active communication and have met annually for 2 years as a group to discuss the issues surrounding fellowship programs, especially given the small numbers involved in training. ABPMR has assisted with organizing the evaluation process for fellows. An evaluation tool for mid-training and completion of training, with the 6 competencies used as a guide, is available from the ABPMR.

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Certification in PRM 

The ABPMR has offered the subspecialty examination since 2003, initially to those with experience in practice. At present there are 141 PRM subspecialty certificants through ABPMR [8]. Since 2008 the requirement has been completion of an accredited fellowship program or temporary eligibility criteria (through 2011) with appropriate supporting evaluations [9]. The ABPMR website provides information about requirements for certification [9].

The most significant response to the examination occurred in the first 5 years and for the most part represents those with practice experience. The PRM examination can also be used to complete the proctored examination requirement of Maintenance of Certification by certified physiatrists with or without PRM subspecialty certification. Because PRM subspecialization is broad and uniquely covers almost the entirety of the PM&R field, Maintenance of Certification is required only within the subspecialty at this time; this will maintain both the general certificate and the subspecialty certificate.

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Challenges to PRM Training 

The cost for training has become more problematic with recent limitations to the length of support for postgraduate training. In addition, funding for either the combined training or for fellowship training has become more difficult as finances become tighter in academic medical centers. Despite these funding challenges, the number of PRM fellowship training programs has increased. We believe this is because of the recognition by institutions that PRM is currently an under populated specialty that provides a critical and required clinical need to the ever growing population of children with disabilities.

However, the number of candidates applying to these programs has not significantly increased in recent years. There are several potential explanations. The limited experience within residency training programs does not foster interest in the subspecialty, and pediatrics is often not the interest of resident candidates entering the field. For medical students interested in PRM, there are even fewer experiences available in most medical schools. Furthermore, the 2 additional years of training and the perception of lower annual incomes for those practicing in PRM are difficult to compete with the reported incomes of those in other PM&R practices. These reasons result in lower interest, fewer candidates, and unfilled training positions. As a result, the fellowship programs are generally small, with limited faculty and few fellows at each site.

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Conclusions 

PRM education encompasses a training experience that exposes residents to a broad spectrum of disabilities from prematurity to geriatrics, covering all the traditional elements of PM&R, combined with the dynamic changes occurring during growth and development. At the core, PRM addresses the issues of disability, function, and quality of life, independent of disease process. Recent advancement in medicine has increased the life expectancy of children with various diseases. Children with spina bifida, muscular dystrophy, and other diseases are living into and beyond young adulthood.

There is an obvious need for the long-term care of children with disabilities and adults with childhood-onset disabilities. The physiatrist provides a distinct role in their care that is not typically provided by any other specialty. It is clear that PRM subspecialization has enhanced the care of children, adolescents, and adults with childhood-onset disabilities. However, there continues to be a relatively small cadre of trained and certified PRM specialists, and strategies must be developed to sustain the subspecialty and meet these patients' health-care needs. Our professional organizations are continually considering ways to improve the visibility of the specialty. Increasing the number of interested medical students and PM&R residents is of prime importance to the continued health of the subspecialty. The addition of PM&R or PRM chapters within textbooks frequently used by medical students or other specialty practitioners (eg, internal and pediatric medicine texts) could be effective. Continued efforts through the American Association of Medical Colleges might focus on curriculum specific goals and objectives that incorporate disability, transitions of care, and aging with a disability.

In summary, the following principles of PRM subspecialty training and certification are important: (1) to establish clinical and regional centers of excellence; (2) provide a sustaining pool of practitioners for the management of patients and their families requiring specialized services; (3) maintain faculty with high level expertise for teaching principles of PRM to core residencies in PM&R, other primary care, specialty groups, and other health professionals; (4) sustain a cadre of leaders to provide needed spokespeople to advocate for the needed health care for children, adolescents, and adults with childhood-onset disabilities and those who serve them; (5) support expertise in research (including outcomes research, evidence-based interventions, prevention, behavior, and health service delivery models of care); (6) develop and implement effective linkages between research and practice, involving consumers, assuring quality, and enhancing service delivery; and (7) promote consumer involvement in policymaking and decisions through physician experts in PRM. By addressing these issues, PRM will be able to provide advancements in the clinical, educational, and research areas of caring for children and adults with childhood onset impairments and disabilities.

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References 

  1. Stein REK. Trends in disability in early life. In:  Field MJ,  Jette AM,  Martin L editor. Workshop on Disability in America: A New Look. Washington DC: The National Academies Press; 2006;
  2. Newacheck PW, Taylor WR. Childhood chronic illness: Prevalence, severity, and impact. Am J Public Health. 1992;82:364–371
  3. Application Broker, Version 9.1. http://www.census.gov/cgi-bin/brokerAccessed October 9, 2009
  4. American Council on Graduate Medical Education. Physical Medicine & Rehabilitation Program Requirements. http://www.acgme.org/acWebsite/RRC_340/340_prIndex.aspAccessed October 9, 2009
  5. Sneed RC, May WL, Stencel C, Paul SM. Pediatric physiatry in 2000: A survey of practitioners and training programs. Arch Phys Med Rehabil. 2002;83:416–422
  6. American Council on Graduate Medical Education. List of ACGME Accredited Programs and Sponsoring Institutions. http://www.acgme.org/adspublic/Accessed November 9, 2009
  7. DeLisa JA. Physical Medicine and Rehabilitation/Pediatrics. Combined Residency Training Programs, American Board of Medical Specialties. 1998;55–72
  8. The American Board of Physical Medicine and Rehabilitation. Examination Statistics. https://www.abpmr.org/candidates/exam_statistics.htmlAccessed November 9, 2009
  9. The American Board of Physical Medicine and Rehabilitation. Certification: Booklet of Information, 2009-2010 Examinations. https://www.abpmr.org/boi/Cert_BOI.pdfAccessed November 9, 2009
  • † Disclosure: nothing to disclose
  • ‡ Disclosure: nothing to disclose

 Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org

PII: S1934-1482(09)01531-7

doi:10.1016/j.pmrj.2009.11.004

PM&R
Volume 1, Issue 12 , Pages 1055-1057, December 2009

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