Reflecting on the past often helps anticipate and prepare for the future, a key step to organizational learning and improvement.1 This special edition of the American Journal of Physical Medicine and Rehabilitation was assembled to commemorate the 75th anniversary of the American Board of Physical Medicine and Rehabilitation (ABPMR). There are currently 11 living physiatrists who served as the chair of ABPMR. Their service spans 40 yrs, from 1981 to present day. On this significant milestone, it is an opportune time to reflect with the organization’s leaders—past and present—to gain insight into our history as a specialty that has experienced dramatic growth.

REFLECTIVE APPROACH

All of the living chairs of the ABPMR (Table 1) shared personal reflections on the state of the board and the field of physical medicine and rehabilitation (PM&R) in general through an open-text questionnaire (Table 2). Individual text responses were collected and translated into a conversational piece with each chair identified by last name, followed by two digits representing the first year they served as chair of the board. One chair (JTM) served the role as discussion facilitator, and all chairs approved the final translated conversation as accurate interpretations of their input.

TABLE 1 - Past and present ABPMR board chairs First Year as Chair Chair Name Discussant Code 1981 John F. Ditunno, MD Ditunno_81 1984 B. Stanley Cohen, MD Cohen_84 1988 John L. Melvin, MD Melvin_88 1993 Joel A. DeLisa, MD DeLisa_93 1998 Nicolas E. Walsh, MD Walsh_98 2005 Margaret A. Turk, MD Turk_05 2007 Dennis J. Matthews, MD Matthews_07 2010 Teresa L. Massagli, MD Massagli_10 2013 Karen J. Kowalske, MD Kowalske_13 2016 Anthony E. Chiodo, MD Chiodo_16 2019 James T. McDeavitt, MD McDeavitt_19
TABLE 2 - Reflective questions for the ABPMR board chairs Growth of the Field  How would you describe the characteristics of the typical physiatrist entering the field during your time on the board? What attracted physicians to our specialty?  What were the predominate clinical interests of physiatrists?  What were the major drivers of growth in the specialty? Practice of PM&R  List a few (2–3) factors that drove practice satisfaction during your leadership era.  List a few (2–3) factors that drove practice dissatisfaction.  How did the economics of PM&R practice evolve?  What was the greatest scientific innovation during this time? The greatest practice innovation? Organizational Culture  Think about the culture of the ABPMR Board of Trustees under your leadership. What single word comes to mind that describes the culture?  What were the strategic and operational priorities of the ABPMR?  What was the greatest challenge faced by the ABPMR during your tenure?  What was the board’s greatest accomplishment? What was the board’s greatest failure/missed opportunity? PM&R today  Please provide a brief statement on your perspectives of PM&R today—strengths, challenges, opportunities.
THE PAST AND FUTURE OF PHYSICAL MEDICINE AND REHABILITATION McDeavitt_19

I want to start by thanking each of you—for your service to the ABPMR, but also for agreeing to participate in this discussion. Forty years is a long time, and has been a period of incredible change. There are many topics we could cover—and much of our history has been well documented2–5—but I really want to focus on issues that board leadership faced during your board chair tenures. Dr Ditunno, your term as chair was the earliest among those in this discussion, so perhaps you can start us off. What were the big issues facing the ABPMR in the early 1980s?

Siloed in the Basement Ditunno_81

First of all, I think you have to acknowledge that looking back, PM&R was starting to undergo a huge transformation, which fundamentally changed the field. Prior to that time, there were essentially three major practice environments for physiatrists. One group worked in outpatient private practice. They typically employed a therapist or two as part of the practice and focused on musculoskeletal issues. The second group worked in departments of acute care hospitals. At that time, hydrotherapy (e.g., Hubbard tanks and whirlpools) was a central component of the departments. Because of the weight of the water, departments were almost always in the lowest part of the building, leading to the stereotype at the time that “PM&R is always in the basement.” There was a third group that practiced in free-standing rehabilitation hospitals. A few of the facilities were outstanding—and are names you would recognize today—but many were marginal. As a gross generalization, none of these careers carried much prestige, and were not particularly well-remunerated. They were clearly not attractive to the best students. Although our field has been blessed with great academic pioneers from its inception, PM&R was not the typical professional landing site for a top-tier student.

A Turning Point: Changes in Practice Setting and Reimbursement Cohen_84

Then suddenly things began to change, driven by the proliferation of inpatient rehabilitation hospitals. This practice option was not necessarily new, but started to greatly expand. Physiatrists ran these hospitals and units. The patients stayed for at least a couple of weeks to up to a few months.

Melvin_88

I want to add one important point. Prior to 1983, acute care hospitals were paid by insurers at a “per diem” rate. The longer a patient stayed in the hospital, the more revenue the hospital collected. In 1983, prospective payment was rolled out nation-wide for Medicare patients (diagnosis related groups, or DRGs), and soon spread to commercial insurers as well. This was a huge change for hospitals. Notably, rehabilitation units were exempt from DRGs, and became one of the few service lines where hospitals could continue per diem charges. There was a significant financial incentive to open and expand inpatient rehabilitation facilities (IRFs), and physiatrists were needed to run them.

Emergence of Financial Incentives and IRFs: The Demand for Physiatrists Boomed Walsh_98

This was transformational for our field. Hospitals were suddenly desperate to recruit qualified physiatrists. Jobs were waiting for our residents all the time. We were continually harangued by recruiters: “Who do you have coming out of training? Are they available?”

McDeavitt_19

Yes, all of us who lived through this transition saw the benefits to the field of this rapid growth. Unfortunately, we have also probably seen some contraction of IRFs since prospective payment finally caught up with rehabilitation hospitals in 2002. But recall, this is a conversation about the ABPMR—the accrediting body for physiatrists. How did these changes impact what was happening with the board?

DeLisa_93

Fundamentally, we needed to up our game. We quickly moved from a small, under-the-radar specialty, to a medium-sized specialty that was attracting a lot of attention. Ambitious and highly qualified trainees expected excellence in training, so residency programs were driven to improve. New programs began to proliferate. The field began to integrate more thoroughly into organized medicine. Just as physiatrists in practice needed to professionally engage with their clinical colleagues to demonstrate the value of PM&R, the field needed to engage with other boards and organized medicine to earn the respect of our colleagues. I was proud of the leadership our board displayed, and was fortunate to have had an opportunity to go on to serve as chair of the American Board of Medical Specialties (ABMS). Dr Barry Smith also recently served as ABMS chair. A physiatrist in this leadership role would have been highly improbable prior to the 1980s PM&R renaissance.

A Work in Progress: Strengthening PM&R Training, Exposure, and Research Ditunno_81

I would add, as training programs improved, there was a strong consensus among our leaders that we needed to introduce better research training for residents. This posed a number of challenges. At the time there was little funding for rehabilitation research. There were few accomplished researchers to serve as mentors and role models. The field did not really have much of a research culture. We have made tremendous progress as a field, but still have a long way to go.

DeLisa_93

Absolutely. The same goes for training opportunities—great progress, but a long way to go. Our specialty still only has a presence in about 50% of US medical schools.6 If all these schools wanted to start a department or training program tomorrow, we would be hard-pressed to produce enough qualified chairs.

Massagli_10

And I would add, PM&R to this day is still a specialty that medical students discover late in their training.

McDeavitt_19

It seems like this era—the 1980s into the 90s—was also when we started to see a real challenge emerge for the ABPMR. Younger physiatrists started to demand certification for subspecialty training.7 We now have six subspecialty certifications. What do you think drove this desire to specialize, which remains strong today?

Melvin_88

I think there were a number of reasons. There was a lack of prestige and respect for PM&R in many parts of the country. We also had influential physicians in other specialties challenging the need for physiatrists at all. They believed the needs of our patients could be met by non-PM&R trained specialists. I do not think most of these physicians—and they were thankfully a minority—really took the time to understand the scope and philosophy of PM&R. Subspecialization in some cases helped to enhance our credibility.

Turk_05

Specialization also helped to define our expertise for the House of Medicine, and the ABMS in particular. At a minimum, it was important defensively as other fields were driving subspecialty certification that overlapped with work done by physiatrists. During my time on the board, we created opportunities for certification in Sports Medicine and Pediatric Rehabilitation Medicine. These certification pathways helped protect these practice options for physiatrists, while also more sharply defining the scope of our field. We cannot let our guard down on this one. There is still limited exposure to PM&R—or the needs of people with disabilities—in medical school. Many non-physiatrists believe physiatric competencies can be easily accomplished with little training.

Walsh_98

There is another point to be made here. Our tact in general was to cooperate with other certifying boards in other specialties. As the demand for subspecialty certification increased, many of the boards insisted on total control of the subspecialties. We were more interested in collaboration. That is why today there are multiple pathways to become pain, sports, or peds certified. Other boards turned the process of specialty approval into a turf war, which at times became very heated and very ugly. Over time, the collaborative approach consistently taken by the ABPMR proved to be the wisest path.

Trustworthy Examinations and Culture Shifts Through Collaborative Leadership McDeavitt_19

Let us briefly discuss another area which I think has improved dramatically, and which must be a core competency of any accrediting board—the production of high-quality examinations. As someone who took part I and part II in the early 1990s, volunteered on multiple exam committees and now has an opportunity to see the statistical performance of the exams, there really has been dramatic improvement.

Matthews_07

Part of that improvement was driven by engaging excellent psychometric support. We really enjoy the support of very high-level statistical expertise, which gives me great confidence in the validity of all our exams.8 It also permits us to perform some fundamental research on accreditation.

Chiodo_16

Which in turn supports the current board vision, which is—in part—“to provide… a dynamic, reliable, and valid certification process.” I think we are one of a very few ABMS boards that has this level of commitment to rigorous study of our processes, backed up by peer-reviewed publications.

Walsh_98

In particular, the improvement in the part II exam has been impressive. When I started on the board, there was no standardization of the exam, and it was rife with inconsistencies. I asked Dr Joel DeLisa, the immediate past chair, to start an oral examination committee, which started by just observing the process. It has taken a couple of decades, but now there is a very high degree of standardization of the oral exam, and it is highly reliable.9 This was one of the great successes of the board.

Matthews_07

There was also a shift in culture within the organization. When I was first elected to the board, there were two factions: part I and part II. The more senior board members were with part II, and there was little collaboration or coordination between the committees. My first act as chair was to reshuffle the exam committees and improve transparency. I think this was a big step in creating a more collaborative board.

Massagli_10

Along with limiting terms of board members and board leaders. The steady infusion of new voices onto the board has also driven a very collaborative cultural change.

Chiodo_16

I agree we have made huge progress in our exams. In addition, the experience we gained, and the expertise we developed paid other dividends as well. When the pandemic hit, we were able to pivot rapidly to deliver the oral examination virtually, and the board subsequently decided the exam will remain virtual, reducing diplomate cost of travel and time away from work. We could not have made this rapid transition if the exam itself was not rock-solid. I was very impressed when we learned the virtual exam performed statistically every bit as well as the face-to-face version.

Kowalske_13

In another major transition, we eliminated the 10-yr recertification exam, and replaced it with Longitudinal Assessment for PM&R (LA-PM&R). Replacing the traditional high-stakes examination with a reliable, valid and convenient process relevant to practice10 was very well received by the field. The experiences gained in exam development over the past 30 yrs really helped prepare us to make this transition successfully.

Addressing the Complexities of Continuing Certification McDeavitt_19

I am glad you brought this up. I would like to talk about the elephant in the room, a major issue for our board, and all ABMS boards over the past several years: Maintenance of Certification (MOC).

Chiodo_16

Now known as “Continuing Certification (CC).”

Massagli_10

This really was a significant dissatisfier for our diplomates. Prior to 1993, you passed your written exam, passed your oral exam and you were done—board certified for life. Many people resented the loss of lifetime certification. The inauguration of MOC was viewed as a burden without proof of benefit.

Walsh_98

Although the majority of the board recognized the rationale behind the MOC transition, there was not unanimity of opinion. This really was driven by the American Board of Internal Medicine, who made some significant missteps early on. In my opinion, they took a very “medical school” approach to certification that was very heavily driven by standardized testing.

Kowalske_13

Fortunately, the approach has evolved, and the process is much more provider relevant than before. This process evolution created its own set of problems for the board. We were trying to be as transparent as possible. Explaining the changing concept of continuing certification was a challenge.

Turk_05

The board was also aware these changes were not occurring in a vacuum. Physiatrists were dealing with integration of electronic health records into practice. The regulatory burden imposed by CMS and insurers weighed people down with administrative tasks. Burnout started to be more of problem.11 Fundamentally, the board did not want to add to the stress of practice, and we really tried to decrease the burden of accreditation.

Chiodo_16

Dr Karen Kowalske already mentioned a good example of burden reduction: the transition to LA-PM&R. Almost universally, physicians prefer the intermittent, online certification process to the traditional examination. Probably the biggest current dissatisfier in the process is part IV of Continuing Certification—the requirement for a practice-based process improvement project (or PIP). This process has evolved as well, and should not be onerous to complete. The ABPMR web site has great tools in place—PIP Wizard, sample projects, instructional videos—to make the process as easy and practice-relevant as possible.

Melvin_88

Although MOC/CC was not warmly embraced by many physicians, in the end probably the greatest accomplishment of the ABPMR over the past several decades was the implementation of time-limited certification.

DeLisa_93

It was necessary. Recall the ultimate purpose of a professional accrediting body is to give the public confidence that a given provider has a basic level of competence. It is hard to argue in the face of modern medicine’s information explosion, with the current pace of clinical change, that a test administered in your 30s is an assurance of competence in your 60s.

Future Priorities: Addressing Diversity, Equity, and Inclusion and Restoring Morale, Well-Being, and Meaningfulness in Work McDeavitt_19

There is so much more we could discuss, and I hate to wind this down. But let me finish by asking a general question. We have talked about the past. What are the future challenges and opportunities for our field and our board?

Kowalske_13

I hate to lead with a negative, but provider burnout is a real problem,11 and will not be addressed by yoga classes or gift cards. Individual physicians are asked to do more and more for the same—or diminished—reimbursement. Compassion is low. Thinking like a physiatrist is based upon being patient-centered and compassionate. I worry that this is being lost.

Turk_05

There is another important point we cannot ignore. PM&R is the only medical specialty that advocates—within health systems and in society as a whole—for the needs of people with disabilities. Over the years, I feel like our field has done a good job of advocating for providers of PM&R services, but I fear we have lost some of our commitment to patient advocacy. As an example, the pandemic resulted in many unfortunate decisions. Hospitals felt IRFs could be closed or repurposed as COVID-19 units, without much thought as to the needs of people with newly acquired disabilities. We have a responsibility to serve as strong advocates for the patients we serve.

Matthews_07

There is much to be grateful for as well. We have made tremendous progress witnessed by everyone involved in this conversation. PM&R is very well established and respected. Departments have demonstrated the importance of rehabilitation services in the care delivery system. Physiatrists have assumed leadership roles in major health systems and universities.

Ditunno_81

It is also a much bigger tent. Recent boards have been evenly split between men and women, whereas we were male dominated. As evidenced by this conversation, board chairs now reflect gender diversity. We are also making good progress with racial and ethnic diversity. We need to approach this issue with the same discipline12 we have used to improve in other areas.

Massagli_10

I have always thought our biggest strength as a field is that we are not disease driven—we are people and function driven. When conditions emerge that impair function we have been there to help. The trauma produced by two World Wars, Vietnam, the Middle East and Afghanistan. Polio. Cancer. Aging. COVID. Our specialty has its challenges, and always will. But there will always be a real need for what we do. If I could choose this specialty again, would I? Absolutely. The diversity of conditions we treat makes our work intellectually stimulating. Technology in the future is going to revolutionize the way we are able to care for people. Fundamentally, I cannot think of another specialty that affords the real privilege of entering the lives of people and families in need, in a real and substantive way.

Cohen_84

Physiatrists make a lasting difference in lives of our patients. It has been a real honor to serve them and our field.

McDeavitt_19

We will end on that positive note. Thanks to all for participating in this discussion, thank you for your contributions the specialty and happy 75th anniversary.

ACKNOWLEDGMENTS

The authors thank Nital P. Appelbaum, PhD, Department of Education, Innovation and Technology, Baylor College of Medicine, for her valuable editorial assistance.

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