Physiatry: What's the End Game?
Article Outline
In 1995, when I was a fledgling physiatrist, I discovered a mentor performing phenomenal treatments on patients. These treatments were something I had never been exposed to, much less seen actively practiced by a physiatrist. I was astounded because I had spent 4 years in medical school and another 4 in residency, naively believing I therefore carried a vast knowledge about spine and musculoskeletal conditions. After observing my future mentor, it was clear that was not the case.
His technique had a 3-point foundation: effectively communicating with patients; having a clear understanding of the conditions of their injury; and then evaluating them more thoroughly than I had ever previously observed. He examined disconcerted, underwear-clad patients who were, sadly, unused to disrobing in such circumstances. His scan concentrated on detecting dissymmetry from head to toe. He placed his hands on patients, discovering slight changes in muscle tone and variances in the texture of small islands of skin; he could feel a restricted joint and discover a failing muscle unable to balance the motion of a limb. His ability to diagnose biomechanical anomalies was not a gift, it was something he had learned and he assured me, something I could learn as well.
And his relationship with patients did not stop with a fluid and detailed evaluation. Those same hands and that same vault of knowledge tied his discoveries to a treatment plan, frequently treatments that he performed in the office. An inability to perform a particular motion in a particular way became a specific exercise carried home from the clinic visit. A plan of action evolved that included explanation, education, and involvement. The patient entering the exam room, wary and bemused, left charged with personal responsibility to making the choices that would lead to resolution of the problem. I was so impressed by my mentor's perspective that I applied to and spent a year as his fellow. Incidentally, his therapeutic assets also included the use of fluoroscopically guided epidural injections, and that I would learn from him as well.
By now, there is not likely a physiatrist unfamiliar with fluoroscopically guided procedures. Even in my relatively short life as a physiatrist, technological progress has profoundly changed medical care. We have advanced to placing a needle tip with 3-dimensional accuracy at any point in the human body, injecting a magical substance or placing an electronic miracle. But has technology really improved health care?
The use of injections for treatment of lumbar radiculopathy and axial lower back pain remains controversial; further, the gap between usage and proven efficacy remains substantial. According to the Center for Medicare and Medicaid Services records, physiatrists accounted for an 838% increase in epidural, zygapophysial, and sacroiliac joint injections between 1994 and 2001, second only to radiologists in the rate of increase over that period. Inflation-adjusted Medicare costs for physician fees alone increased 7-fold from $24 million to $175 million in that same 8-year period. This compares with a 12% growth of the Medicare population and stable prevalence of low back pain diagnoses [1].
Available data to monitor the use and efficacy of these procedures are largely limited to the Medicare population. Some would legitimately argue cautious interpretation of these data because it most likely represents an older population. Indeed, the U.S. population grew approximately 11.8% between 1997 and 2006, during which Medicare beneficiaries increased by 12.7%, according to the CMS Carrier Claim Record. But at the same time, the number of Medicare beneficiaries receiving interventional pain medicine procedures increased by 169%. The average number of interventional pain medicine visits per beneficiary increased from 2.16 in 1997 to 2.22 in 2006. Epidural procedures increased by 145%; zygapophysial joint interventions by 624%; and discography by 192% [2].
Physiatry, by principle and philosophy, is a specialty that emphasizes minimizing disability, leading to the logical question: has the increased expenditure on procedures achieved this goal? Easily accessible data are limited; however, according to the Centers for Disease Control and U.S. Census Bureau, the 3 most common nonpsychological causes of disability are, in descending order, arthritis, back or spine problems, and heart-related problems. The prevalence of disability between 1999 and 2005 remained unchanged, from 22% to 21.8%. However, the absolute number of individuals reporting disability for that same time increased by an estimated 7.7%, interpreted as reflecting an increase in the percentage of the aging population and baby boomers on the total population [3].
Interventional pain medicine was born long ago as an adjunct primarily to anesthesia, although its history is girded on the efforts of many specialties, physiatry not the least. Common ground shared by proponents of interventional pain medicine is their frustration with specialists who do not wholeheartedly pursue a thorough knowledge of all interventional procedures. It is difficult to quibble with this position. It reflects an expected level of professionalism and does not preclude the notion that procedures be performed only on the right patient at the right time for the right indications. The argument being that if all interventional pain physicians, regardless of specialty training, held the same broad knowledge and applied currently accepted ethical reasoning to all their clinical decisions, percutaneous interventions would only be used appropriately. However, this argument assumes the existence of accepted standards of appropriate use of injections and a common objective, that is, the quest for the elusive pain generator or the maximization of function.
The premise that interventional pain medicine is one entity, with all practitioners starting at the sound of the same pistol, is just not the case. Interventional pain physicians are bred from 2 primary specialties, anesthesiology and physiatry. The temperament of the medical student that chooses one specialty over the other used to be different; however, because the subspecialty opportunities within these 2 specialties have merged, that argument may no longer be valid. Still, once the trek through residency begins, the paths of a physiatry and anesthesiology resident can hardly be considered parallel. Even if a physiatry residency program has greater than average opportunity for its residents to begin learning interventional procedures, the fundamental driving force of physiatry—pursuit of functional restoration—should harvest a different perspective when comparing a graduating physiatrist with a graduating anesthesiologist. Whereas an anesthesiologist may find procedures the fuel to his or her career, a physiatrist should more likely find them to be one of many tools toward achieving a positive functional outcome.
Certainly, striving to procedural excellence is a noble endeavor and on its face is difficult to slander. Conversely, an unfortunate side effect of such unidimensional zeal is the inability to recognize what is sacrificed. Physiatrists who pursue interventional procedures may forego their unique training and philosophy in search of more technological expertise. Many will argue (including me) that to be a supremely competent interventionalist, a physiatrist must abandon the functional outcomes essential to physiatry. It is temporally impossible to be comprehensively knowledgeable and experienced as an interventionalist and maintain the time necessary to evaluate, educate and manage patients as a complete physiatrist. The only option is one, the other, or a hybrid.
The lure of procedures is tangible. They are clean, precise, easily quantifiable, and (at least at the present) comfortably reimbursable. The reassurance one feels entering the day with a list of well-defined objectives, completing that list, and traveling home exhausted but content cannot be overstated. Admittedly, it is what many would like to achieve—a neat, orderly life. Perhaps it becomes a subconscious engine carrying us toward a different perspective. It has also enticed many of us to active involvement in procedure-specific specialty associations, often at the expense of our primary specialty organization.
But as physiatrists, should we not recognize what our physiatric training has provided? Do we not see that the physiatric approach to management of musculoskeletal and spine complaints is unique, more so than the technical expertise required for performing percutaneous procedures? It may be counterintuitive for some to accept the notion that performing percutaneous procedures is relatively easy. No doubt, the clinical risks are greater, but procedures are not a reflection of complex human interaction but rather target practice. Even if one stumps the argument that target selection is critical, it is still not as troublesome as fully evaluating another human being—her history, cultural background, emotional and psychological perspective, biomechanical anomalies and functional needs—and then successfully engaging her in the process of her own rehabilitation.
I listen to the expansive debate on the foibles of the current health-care system, and preferences on how those faults might be resolved. I contend that the limiting factor on the health of health care is the objective. We physiatrists speak with a modest but not a weak voice. How often is it that the quietest person in the room may have the most profound statement to make? Physiatrists, regardless of individual clinical perspective, should understand better than all the collective voices in the room that the objective should always be function.
It is indeed a fine line that we straddle. There are many questions to ponder. For example, when we overly pursue technology, can we adequately provide the opportunity for our patients to achieve their maximal goals? If we believe that shared decision-making is a fundamental premise of the physiatric approach, do we have the time necessary to educate and involve patients if that limited time is passively applied in a fluoroscopy suite? If a physiatrist provides a procedure that can be performed by another specialist, who then provides what a physiatrist can provide? There are only 8000 physiatrists in this country. The opportunity for patients to explore the unique path created from a physiatric perspective is limited. If that number is diminished by those of us who pursue technological expertise at the expense of fully educating our patients, are we really likely to achieve what is needed for our healthcare system and specifically for each of our patients?
What drove me to pursue a fellowship in the mid-1990s, especially at a time when outpatient rehabilitation facilities were thriving, was the intense curiosity I had with my mentor's perspective and the goal of reproducing that perspective in my future clinical practice. I do not disagree with the evolution of subspecialty training. The swollen knowledge of medicine has long ago surpassed the ability for any one person to maintain fluent proficiency. Even within the primary specialties, the need for subspecialty expertise is certain, but accepting that reality is not adequate justification for our clinical decisions. We are influenced by many things, perhaps not more than the current health-care reimbursement structure, which rewards objective rather than subjective patient interactions. However, we must remain attentive to those influences and never forget that the technical skills we have learned in fellowship training, although significant, are not nearly as important to society as the philosophy instilled in us during our physical medicine and rehabilitation residencies.
References
- . Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine. 2007;32:1754–1760
- . Analysis of growth of interventional techniques in chronic pain in Medicare from 1997 to 2006. Pain Phys. 2009;12:9–34
- . Prevalence and most common causes of disability among adults—United States, 2005. MMWR. 2009;58:421–426
Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org
PII: S1934-1482(09)01649-9
doi:10.1016/j.pmrj.2009.12.011
© 2010 Published by Elsevier Inc.
