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aintaining Health, Wellness, and Fitness: A Newiche For Physiatry?

tuart M. Weinstein, MD

SMSteD

n 1996, a physical medicine and rehabilitation manpower study concluded that the overallemand for physiatrists would likely exceed supply through the year 2015 [1]. A revisedupply and demand projection for physiatry through the first quartile of the 21st century [2]ostly supported that original study, identifying several potential modifying factors includ-

ng an alteration in the rate of training of physiatrists in the United States; the impact ofealth care reform (then managed care; now the 2009 iteration); and the state of publicwareness of physiatry. Regarding this latter factor, the original study in fact stated, “If therofession is successful in informing the market regarding the advantages of physiatry, therofession can continue to grow without experiencing excess supply, in the aggregate, forhe foreseeable future.” These two reports served as the basis for the American Academy ofhysical Medicine and Rehabilitation (AAPM&R) to direct resources to a long-term mar-eting campaign for the specialty and its constituency.

But understanding and appreciating the maximal value of physiatry to individuals and toociety as a whole has been a moving target. From 1950 until 1980, physiatry was knownrimarily in the context of classical inpatient neurorehabilitation. Beginning in the mid-980s, the emphasis moved toward outpatient management of musculoskeletal (MSK)isorders. And in the past decade, physiatry has made its mark in interventional painedicine. As a specialty, physiatry has demonstrated, in these successive eras, the ability to

e dynamic in responding to patient/consumer demands and needs: first providing the skillsecessary to address the needs of the war-injured; next emphasizing diagnostic andherapeutic acumen in the treatment of what are primarily nonsurgical problems (ie, MSKisorders); and finally combining knowledge of functional anatomy and physiology withechnology to provide minimally invasive therapeutic procedures.

However great the value of physiatry has been over these several decades, competitionith other medical specialties (neurology [neurorehabilitation], primary care and orthope-ics [MSK medicine], and anesthesiology and radiology [pain medicine/interventions]) willertainly tilt the supply/demand ratio toward an excess of physiatrists. Therefore, itehooves physiatrists to continue to identify a niche that both maximizes service value and

s not yet saturated by other specialties. Further, it should be an area that is vastlyesearchable and that lends itself to performance measures. And finally, it should be a fieldhat is applicable to any physiatrist. So what is this niche area? Maintaining health anditality through prevention and wellness/fitness training.

Historically, physiatrists have established themselves as experts in treating the secondarympairments associated with many types of neurological, musculoskeletal, cardiovascular,nd other injuries and diseases. Certainly, many physiatrists prescribe rehabilitative exer-ises for their functionally impaired patients. It seems a natural transition to apply thatnowledge and skill toward emphasizing wellness and fitness in able bodied persons as wells persons with disabilities. AAPM&R has tacitly acknowledged the importance of associ-ting the specialty with this concept as evidenced by its support of the combined Americanollege of Sports Medicine/American Medical Association initiative, Exercise is Medicine [3],nd as a participating member of the US Bone and Joint Decade initiative [4]. Yet for manyndividual physiatrists, assessing inactive but otherwise “healthy” people for the purposes ofrescribing a comprehensive exercise program is not familiar territory. This idea is furtherxplored by Edward Laskowski, MD, who has offered an Invited Perspective relating to thisopic in this issue of PM&R [5]. Dr Laskowski is a physiatrist, professor at the Mayo Clinic

ollege of Medicine, co-director of the Mayo Clinic Sports Medicine Center, former member

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M&R © 2009 by the American Academy of Physical Me934-1482/09/$36.00 Vo

rinted in U.S.A. D

.M.W. University of Washington, Harborviewedical Center, 325 Ninth Ave., Box 359721,eattle, WA 98104. Address correspondenceo: S.M.W.; e-mail: smw25@u.washington.duisclosure: nothing to disclose

isclosure Key can be found on the Table ofontents and at www.pmrjournal.org

dicine and Rehabilitationl. 1, 793-794, September 2009

OI: 10.1016/j.pmrj.2009.08.451793

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f the President’s Council on Physical Fitness and Sports, andas a strong interest in research and a clinical interest intness training. I am sure that you will find his thoughtsbout the role of physiatrists in the management of obesitynd inactivity thought provoking.

It has been long been my contention that while physia-rists are very fluent in the area of rehabilitating patients fromnjury or disease, they are (as a whole) inexperienced andnprepared to design training programs for fitness and vital-

ty. In general, physiatrists (for that matter, most clinicians)re well trained for identifying and treating pathology, butften have just a cursory understanding of exercise physiol-gy and fitness. In order for physiatrists to gain the fund ofnowledge necessary to develop this expertise, this is an areahat will require a dedicated curriculum. And for manyeasons this makes sense: exercise prescriptions are already

art of the physiatry culture; promoting exercise enhances a

ealthy society; physiatrists can develop a niche area ofaintenance that is not yet monopolized; health mainte-ance and maintenance may fit nicely with the concept ofalue-based reimbursement; and this may just turn out to begreat new marketing strategy.

EFERENCES. Hogan PF, Dobson A, Haynie B, et al. Physical medicine and rehabilita-

tion workforce study: the supply of and demand for physiatrists. ArchPhys Med Rehabil 1996;77:95-99.

. Hogan PF, Dobson A, Hughes J, et al. Supply of and demand forphysiatrists: review and update of the 1995 physical medicine andrehabilitation workforce study. A special report. The Lewin Group. Am JPhys Med Rehabil 1999;78:477-485.

. http://www.exerciseismedicine.org/, accessed August 14, 2009.

. http://www.usbjd.org/index.cfm, accessed August 14, 2009.

. Laskowski ER. Action on obesity and fitness: the physiatrists’s role.

PM&R 2009;1:795.