Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

What the heck is a "rehab doc?" Part 1

One medical specialty has managed to avoid (nearly completely) the public eye: Physical Medicine & Rehabilitation (or PM&R). Physicians who choose this specialty are referred to as “physiatrists” or “rehabilitation medicine specialists” or “rehab docs.” But the truth is that very few people understand what they do, and unfortunately the rehab docs haven’t made much of an effort to explain themselves to their peers or the world at large.

A dear friend and mentor once asked me, “why did you choose such an odd ball specialty?” This rather direct question forced me to ponder my career decision, and to determine how it came to pass that PM&R was given the unhappy reputation of “odd ball specialty.” I’ll begin with a little background about the specialty and then explain why I chose to devote my life to it.

The history of PM&R

PM&R really traces its roots back to the American Civil War (1861-1865). This gruesome battle resulted in over 620,000 casualties and over 60,000 limb amputations. The modern specialty of general surgery developed through life saving trial and error on the battlefield. Massachusetts General Hospital, for example, was performing an average of 39 surgeries/year before the civil war, and this increased to 2,427 in the late 1800’s.

But physicians and surgeons were not prepared for the aftermath of war – tens of thousands of maimed and partially limbless now trying to live out their careers in a disabled condition. One confederate soldier, James E. Hanger, lost a leg in the war, and subsequently created America’s first prosthetics company, still in operation today. Unfortunately for the disabled, though, there was no guarantee that appropriate accommodations would be made for them to be fully reintegrated into society.

With the rise of surgery came a major realization: patients did not do well after surgery if they remained in bed. Conventional medical wisdom suggested that bed rest and inactivity were the most effective way to recuperate, but now with thousands of post-operative patients in full view, it became painfully clear that the patients who did the best were the ones that got up and returned to regular physical activity as quickly as possible.

Following this realization, the University of Pennsylvania created (in the late 1800’s) an orthopedic gymnasium for “the development of muscular power with apparatus for both mechanical and hot air massage, gymnastics and Swedish movement.”

A young Canadian gymnast trained in Orthopedic Surgery, Dr. Robert Tait McKenzie, was recruited to U. Penn to develop a new field in medicine: “Physical Training.” Dr. McKenzie created a medical specialty called “Physical Therapy” and he was the first self-proclaimed “Physical Therapist.” He wrote a seminal book on the subject called “Reclaiming the Maimed” (1918) and continued to practice orthopedic surgery until his death in 1938.

Other major medical institutions followed U. Penn’s lead, creating “Medicomechanical Departments” at Mass General and the Mayo Clinic. Technicians were trained to assist in helping post-operative patients to become active and reclaim their range of motion – these technicians were known as “physiotherapists” and formed the first physiotherapy training program at the Mayo Clinic in 1918.

World War I (1914-1918) resulted in millions of additional amputations, thus flooding the health system with disabled veterans. In response, the army created two medical divisions: The division of orthopedic surgery and the division of physical reconstruction. By 1919, 45 hospitals had physiotherapy facilities, treating hundreds of thousands of war veterans.

And then there was polio. Suddenly a viral illness created a whole new wave of disabled individuals, further stimulating the need for orthotics (leg braces and such) and rehabilitative programs.

World War II (1940-1945) resulted in yet another influx of disabled veterans. All the while the medical community was developing innovative programs to maximize veterans’ functionality and integration into society and the work place through the burgeoning field of Physical Medicine & Rehabiltiation.

Key players in the development of the specialty:

Dr. Frank Krusen developed the first physical medicine training program at the Mayo Clinic in 1935 and the “Society of Physical Therapy Physicians” (now the American Academy of Physical Medicine & Rehabilitation) in 1938. He coined the term “physiatrist” to describe the physicians who specialized in physical modalities for rehabilitating patients.

Dr. Howard Rusk founded the Institute for Physical Medicine & Rehabilitation in 1950 at NYU.  Excellent research in the field ensued.

Dr. Henry Kessler founded the Kessler Institute for Rehabilitation, in New Jersey, 1949.  More medical research was developed.

Mary E. Switzer successfully lobbied for the enactment of Public Law 565 which mandated that government funds be channeled towards rehabilitation facilities and programs for the disabled.

What’s in a name?

So as you can see, there is some good reason to be confused about the modern specialty of PM&R. It has undergone several name changes, molded by historical circumstance. Today, physiotherapists (they still go by that name in Canada) or physical therapy technicians have become a well known and respected profession: Physical Therapy.

Physicians who specialize in Physical Medicine & Rehabilitation are called rehabilitation medicine specialists or “rehab docs” or “physiatrists.”

-See Next Post for the rest of the story -
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Give your doctor some flowers?

Richard Reece’s recent blog post echoes my sentiments – that it is important, in the midst of a broken healthcare system (and all the frustration that it creates), to stop and ponder the good things that yet exist. There are flowers popping up between the concrete slabs of our system…

Dr. Reece writes,

This is an anti-hero age. We no longer send bouquets or offer praise or optimism, beauty, life, or achievements.

Instead we doubt, dissect, disparage, analyze, impugn, question, and investigate.

Boy, do we investigate. We investigate Presidents, Vice-Presidents, Attorney Generals, Politicians, Army Generals, Priests, Physicians, and Establishment Institutions. The prevailing attitude is: if they or it have succeeded in our society, something must be wrong. Our most prominent heroes, even Mohammad Ali, have feet of Clay. So we send no flowers, only regrets that things are not perfect.

And physicians?

Well, they are the worst. Imagine. They err like other mortals. They occasionally misinterpret signs, symptoms, and results. They cannot guarantee perfect results under all circumstances. They cannot even repeal the Laws of Nature, or the inevitable Limits of Longevity. Physicians are not even omnipotent, omniscient, or omnipresent

Maybe we should praise our doctors and their institutions, considered many to be “the best in the world.” That may be why the U.S. introduces 80% of the world medical innovations and wins 80% of the world’s Nobel Laureates in Medicine even though we only have 5% of the world’s doctors. Maybe we should give our doctors flowers, instead of defoliating them. Maybe they should be our heroes, rather than our villains. American doctors are not miracle workers, but given limited resources and Nature’s limitations, they are damn good.

I encourage you to read Dr. Reece’s whole post. This excerpt doesn’t do it justice.

And if you’d like to give a shout out to a good doctor you know (in lieu of flowers) please comment here!

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The "non-compliant" patient

It used to strike me as odd that physicians used somewhat hostile language to describe patient behavior – “the patient is non-compliant,” “the patient refused [this-or-that drug or procedure],” “the patient denies [insert symptom here].”

After many years of using these words, I forgot just how inflammatory they are. They became part of my language, and I used them every day to describe people. I’m not really sure how this phraseology became common parlance, but it is a tad adversarial when you think of it. It sets up a kind of us versus them environment. And really, medicine is all about us in partnership with them.

I was reminded of this fact as a friend of mine described a recent “non-compliance” episode. She had been complaining of shortness of breath, and had some sort of suspicious finding on her chest CT. The pulmonary specialist (called a ‘respirologist’ in Canada) recommended a bronchoscopy. Here’s what she says,

I wish I had the chance to explain to my respirologist why I was non-compliant about the bronchoscopy. I got the impression that she thought I was being “difficult” for no good reason, and that I was wasting her time. But the truth is, all my life I’ve had this vague sense that anything big going down my throat was particularly scary to me. I knew I had trouble gagging down pills, but it never occurred to me to mention that. I also chew my food to death in order to swallow it comfortably, but I never thought about that very consciously, either. It wasn’t until months later when I had to undergo surgery for my gallbladder that my anesthesiologist (who had to intubate me) discovered that I had an internal throat deformity.

So my point is that it might be valuable for the respirologist to know that when a patient is very scared of something (especially when she is usually never scared of tests, needles, etc), it could be an important clue. I know now that bronchoscopies are not without risk. A bronchoscopy technician might not have handled the situation nearly as well as that highly-trained, very experienced anaesthesiologist did.

What I learned is this: patients don’t know how to explain things that they haven’t thought much about before, especially when they know that their doc is understandably pressured to get through her scheduled appointments on time. All they know is that they’re scared and that they want to run away. They’re not primarily out to exasperate their docs with their noncompliant attitude. Still, it isn’t easy being a doc. I’m sure noncompliant patients are indeed very irritating. But it isn’t easy being a patient, either. Being looked down upon is irritating too. Not only that, but the patient has a lot more to lose if a mistake is made. But what can you do? Everybody is under a lot of pressure when it comes to medical issues. We all just have to try to be understanding and do our best to work together for a good outcome. It’s in the best interest of both parties, so it shouldn’t have to be a battle!

Have you been a “non-compliant” patient for a good reason? Do share.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Rare skin disorder may be triggered by wart virus?

For those who are faint of heart, please do not click on this link (via KevinMD). This poor man living in Eastern Europe developed a rare disorder (called Lewandowsky-Lutz dysplasia) where he had growths appear on his hands and feet starting at age 14. Many years later the growths are quite disfiguring and difficult to remove.

Some speculate that this may be similar to a warty disorder in rabbits. Either way, it is a little disturbing to me that this condition could be triggered by a virus. Viruses, of course, can be quite contagious…

Any dermatologists out there want to weigh in?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Speed & quality: are they inversely proportional in medicine?

In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).

The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought?  PROBABLY NOT. Will some important detail slip past them?  SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART.  I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.

All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.

Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »