Physiatry Forward: Geographic Disparities in PM&R
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Geographic Disparities in Physiatric Training & Accessibility

Author: Allison Bean, MD, PhD
Chief Resident, The Icahn School of Medicine at Mount Sinai
Past Chair, the AAP's Resident/ Fellow Council (RFC)

As physiatrists, we are well-aware of the statistics: over 25% of adults in the U.S. report having a disability.(1) Access to physiatric care may help to reduce the economic and social impact of disability or even its overall prevalence, particularly for those in medically underserved groups.

In a white paper entitled, “State of the States: Growing Physiatry” recently published in the American Journal of Physical Medicine and Rehabilitation, Danielle Perret, MD, Associate Clinical Professor at UC Irvine, and others highlight the geographic disparities in PM&R education at both the medical school and residency level. They found that only half of medical schools had an associated PM&R department and only 28 U.S. states had active PM&R residency programs. Nine states were found to lack exposure to PM&R in both undergraduate (UME) and graduate (GME) medical education.(2)

One result of an absence of exposure to PM&R in UME is a reduced pool of potential applicants who may have pursued the specialty. However, the consequences are farther reaching: “Exposing all medical students to physiatry would improve national healthcare,” explains Dr. Perret, “members of all medical specialties should be able to make use of physiatric consultants, make appropriate referrals, understand the need for more intensive rehabilitation, and understand the basic concept of human function and its complex relationship to pain, health and disease.”

Another key finding in “State of the States,” is that many states lacking PM&R exposure in both UME and GME are those with the highest prevalence of disability as well as higher opioid prescription rates. Since many physicians practice in the area where they obtain their training, expanding the presence of academic PM&R departments into these areas is essential to improve overall population health. However, starting a new department is not a simple task. Dr. Walter Frontera, Professor at the University of Puerto Rico School of Medicine, has a great deal of experience, having established three departments during his career. According to Dr. Frontera, “the most important challenge was the recruitment of faculty willing to make a commitment to a new department. A second important challenge was the establishment of partnerships with other existing departments, in particular those that are close to the type of clinical work we do. This required a coordinated effort to educate our colleagues about the value of PM&R in an academic medical center.”

With regards to starting new residency programs, Dr. Frontera explains the key to success was “convincing medical student applicants that a new residency training program was good for them and that we had the support of the institution for the long-term.” Another persistent barrier to expanding PM&R residency programs is the cap on Medicare support for GME funding that has been in place since 1997, despite an increasing number of medical school graduates and large predicted physician shortages in all specialties. Fortunately, some of the states “flagged” due to high PM&R needs and/or lack of educational training programs have begun to establish new departments or divisions. New residency programs in Arizona, New Mexico, and Nevada have recently matched their first classes.

“The AAP understands that there needs to be an appropriate number of residency training programs to support the physiatric needs of the United States and internationally.” Dr. Perret explained that the AAP plans to combat disparities in access to physiatric care through efforts “to engage states that have UME and GME PM&R exposure but unmet patient care needs. The goal is to enable appropriate expansions in GME in these areas. The AAP is also looking how to assist training the trainers globally.”

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References

  1. Okoro CA, Hollis ND, Cyrus AC, Griffin-Blake S. Prevalence of Disabilities and Health Care Access by Disability Status and Type Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:882–887.
  2. Perret, D., Sunico, R., Knowlton, T., Kezar, L., Worsowicz, G., & Whyte, J. (2018). State of the States: Growing PhysiatryAssociation of Academic Physiatrists Position Statement Addressing Academic Physiatry and Physical Medicine and Rehabilitation Growth. American Journal of Physical Medicine & Rehabilitation, 97(12), 921-928.