Future Directions in PM&R Joel A. DeLisa, MD, MS Professor & Chair Department of Physical Medicine and Rehabilitation UMDNJ-New Jersey Medical School Immediate Past President - ISPRM

Department of Physical Medicine and Rehabilitation New Jersey Medical School

Core Values of the Field of Physical Medicine and Rehabilitation u u

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Functional improvement is as important as treatment or cure of impairment. We respect all who can help provide care and help our patients improve, including our patients themselves, and their families and friends. Teams can accomplish much more than individuals. Physical agents may be as useful as chemical ones for the treatment and management of diseases.

Core Values of the Field of Physical Medicine and Rehabilitation (Cont.) u

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Education is a key to improving health and function. Our obligation to our patients compels us to change not only the patient, but also our community and our environment. Our roles as physiatrists include social advocacy. Also organized medicine.

Practice – Forces During Future Change u

Consumers are becoming more active and are beginning to use new technologies such as the Internet, to access information about their health. They will ask us many more questions and expect us to have or very quickly obtain the answers

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Exposition of the human genome, and the development of new diagnostic and therapeutic tools will create new opportunities for medical practice. These may create some difficult ethical issues. Who defines quality of life?

Practice – Forces During Future Change (cont.) u

Robotics, alternative medicine and nanotechnology will each have profound effects on the tools and content of medicine.

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Aging: By the year 2050, the world’s population is expected to be 9.5 billion. The 2025 US Census predicted to be 28 million men and 35 million women over the age of 65. Age and disability are correlated. Opportunities for physiatrists.

Practice – Forces During Future Change (cont.) u u

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New healing interventions for central nervous system damage will be developed. Custom engineered drugs based on the individual’s genetic makeup to maximize efficacy and minimize adverse effects will be developed. Drugs that can constrain tissue rejection that will markedly enhance limb transplants and organ/joint replacement. Minimally invasive surgery.

Practice – Forces During Future Change (cont.) u u

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More advanced materials that will allow more and varied implantable devices. Advanced computer technology – artificial intelligence and its effect on medicine. This can greatly affect mobility (wheelchairs, walkers, etc.). Communication technology – areas of telemedicine and telerehabilitation. Wireless access to internet and its effect on our lives.

Economics of Healthcare (Society, individuals) u u u u

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Access to care Noninsured, underinsured Paperwork/forms Physicians Profile 1. Abuse Issues Patient Injury/Patient Safety Pay for Quality Medicine/Medicaid are dominant payers for rehabilitation. Pressures for expense reduction. Are these systems viable? National Healthcare system? Limits, degrees of coverage

Practice – Future Role of Physiatrists u

Clinical Data Collector – Physicians will still collect and interpret information based on patient’s symptoms and appearance. However, this will be supplemented by diagnostic probes and sensors, and in the area of imaging by pattern recognition, by computer intelligence applied to MRI and PET. We will be the experts on EVALUATING AND MAXIMIZING FUNCTION. We should become the experts in managing pain; musculoskeletal, neurogenic and cancer.

Practice – Future Role of Physiatrists (Cont.) u

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Evaluator and prescriber of alternative and complementary medicine – Many of these agents overlap our current modalities and therapeutic areas. Health and Wellness Coach – will probably link to e-mail to improve patient compliance with respect to their health. We should be the experts on preventive and therapeutic exercise.

Practice – Future Role of Physiatrists (Cont.) u

Knowledge Navigator – help patients through difficult choices by developing customized decision trees on treatment, teaching them about sources, and advising them about times when too much knowledge could distract them from the choices presented by their conditions. [Turn information into knowledge].

Practice – Future Role of Physiatrists (Cont.) u

Proceduralist – What is the future role of electrodiagnostic medicine? Can it be made less invasive and painful? Should invasive procedures such as epidural and facet blocks become part of our curriculum? What is the indicator for those procedures? Where are the outcome studies? Role of Musculoskeletal ultrasound?

Practice – Future Role of Physiatrists (Cont.) u

Diagnostician – something that resembles a “palm pilot” will be able to draw samples, run tests, analyze results and calculate a diagnosis. Physicians will play a critical role in synthesizing various data inputs within a knowledge and decision-making framework that is difficult to emulate on even the most powerful computers.

Practice – Future Role of Physiatrists (Cont.) u

Physicians Manager –will spend more time managing other physicians or physicians within our groups and play a leading role in managerial medicine and administration, not only at the hospital and nursing home level, but also in support of new medical technologies, e-health companies and other ventures.

Practice – Future Role of Physiatrists (Cont.) u

Quality Assurance Specialist – must play an increasing role in improving practice through research and monitoring. If we do not do this, we will no longer be the leaders of the health care team. 1. Physiatrists need to be leaders in developing quality of life scales and other functional outcome scales. We must become leaders in measuring health outcomes. Use and role of the ICF?

Practice – Future Role of Physiatrists (cont.) u Leaders

in developing the continuum of care and evaluating the most appropriate and ad cost-effective treatment approach, especially with respect to maximizing function.

Practice – Future Role of Physiatrists (Cont.) u

Treatment of the elderly, especially to maximize function and reduce pain, is a significant opportunity for physiatrists. What is our relationship to Gerontologists?

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Training in palliative care and principles for care of patients at the end of life, should be part of our resident curriculum.

. Observations about International Physiatry u

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We must deal with differences: language, race, culture, economics, politics, and geography. There are many differences, but we can work together within them. We must recognize that people are more alike than they are different. If we work together we can make a difference.

Observations about International Physiatry (Cont.) u

If there were recognized worldwide benchmarks for undergraduate and graduate medical education, we should see results in an elevation of medical care, health status and medical educations – including raising awareness of physical medicine and rehabilitation – throughout the world. I think this needs to be our goal: globalization of medical education.

Observations about International Physiatry (Cont.) u

Assessment drives student learning, regardless of our intent. Our trainees have learned to study what they need to know to pass our examination.

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We should evaluate our trainees within these domains: knowledge, skills, values, and attitudes.

Medical Education u

Can we develop a uniform agreed-upon resident curriculum 1. To this, add training in cost-effective medicine, professionalism, research methodology and experimental design, quality assurance, and legal 2. What is the scope of the field? How is this determined? 3. Who will provide inpatient rehabilitation care for the impaired?

Medical Education (Cont.) u u

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Source of Funding of Training Slots. Common curriculum for medical students. 1. Should we focus on chronic diseases? Certification 1. Subspecialization 2. Maintenance of Certification (MOC)

Research u

For physiatry to flourish as an academic discipline, it must develop a stronger research base. Most of our research is clinical and is more observational, not hypothesis driven. Clinical research is more expensive than bench research because the researcher must control not only the intervention, but also the environmental influences that occur outside the laboratory.

Research (Cont) u

Physiatry needs to integrate basic science research as well as clinical research into its academic base. Nerve regeneration research and pharmaceutical interventions, such as how to improve memory or modify spasticity, are exciting areas that should be central themes for our research., Neuroplasticity was pioneered as a concept by Dr. Paul Bach-y-Rita.

Research (Cont)

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Much of rehabilitation research has concentrated on the motor system. I suspect we will see major advances in augmenting sensory deficits in the coming decade.

Research (Cont) u

Functional neuromuscular stimulation uses electrical stimulation of the nervous system to restore function with neurological impairment. Applications involve both the sensory and motor systems range from feasibility studies to clinical use. It is important that physiatrists integrate these advances into our training programs and practice.

Research (Cont) u

Physiatry has few, if any, general clinical research centers. These are defined as discrete institutional units for clinical research in hospitals and academic medical centers. They are a protected environment for conducting clinical research and play an important role in translation research, i.e., applying basic research in the clinical settings. These centers must be developed.

Research (Cont) u

We must develop, promote and support our physiatry research training programs. We need to hire PhD researchers to work within our departments and to serve as mentors to our trainees. We also need to develop collaboration with researchers from other Departments, including the Basic Sciences.

NIH Definition of Tissue Engineering/Regenerative Medicine u

Tissue engineering / regenerative medicine is an emerging multidisciplinary field involving biology, medicine, and engineering that is likely to revolutionize the ways we improve the health and quality of life for millions of people worldwide by restoring, maintaining, or enhancing tissue and organ function.

Robots and Other Technologies

Nanotechnology A group of emerging technologies in which the structure of matter is controlled at the nanometer scale, the scale of small atoms, to produce novel materials and devices that have useful and unique properties.

To Fulfill our Mission Implicit in providing the best care to our patients is to continuously improve what we are doing as doctors By preventing disease u By improving early diagnosis u By developing better treatments u By ensuring all of our communities have access to the best care Clinical and Translational Research is necessary to advance each of the above goals u

The Elements of Research Capacity To enhance research capacity we need a critical mass of investigators using a team approach to conduct research that will influence clinical practice 1) 2) 3) 4) 5)

Researchers Research culture, environment, infrastructure – space, equipment, personnel Funding – key element and problem Partnerships Metrics

Researchers u

A pool of well-qualified researchers

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Training, mentoring, placing of new investigators

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Recruitment and retention of established investigators

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Strong commitment to inquiry and desire to collaborate with others

Partnerships

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Partnerships with scientists in other disciplines, academic departments, institutions and with patient advocacy groups are vital to enhancing the capacity for conducting high-quality, meaningful research

Metrics u

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Efforts to enlarged research capacity must be complemented by a capability for assessing the capacity over time in order to gauge progress How do you measure productivity? o o o o o o

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Externally funded research expenditures Indirect costs recovered by external grants Number of new grants submitted Success rate of grant submissions Number of new grants funded Number of people who have received research training and who continue to be active in research Number of presentations

Challenges and Obstacles in Clinical Research ¾

Working with humans

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Recruitment and retention of subjects

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Sample size

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Difficulty in defining the intervention

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Indirect measurements

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Variability in physiological and disease states

Conclusions u

Strong research presence – will improve patient care. •

Will ensure academic acceptance of our specialty

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Demonstrating solid advances in rehabilitation research will encourage funding agencies to increase our share of resources.

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Model – Interdisciplinary Research

“ Do not go where the path may lead; go instead where there is no path and leave a trail” Ralph Waldo Emerson