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No organization is an island unto itself
241
ACADEMY
PRESIDENTIAL
No Organization
ADDRESS
Is an Island Unto Itself
Barry S. Smith, MD HE OPENING SESSION of the Annual Assembly allows T each of us who have been fortunate enough to become the President of the American Academy of Physical Medicine and Rehabilitation the opportunity to express ourselves as we complete our year of service to this organization. In our addresses we attempt to state beliefs or visions, either ours personally or for the Academy. The Annual Assembly in this year of 1998 affords a unique opportunity to look both to the past and to the future. This is the 60th anniversary of the Academy, and it is occurring near the end of a century and as we approach a new millenium. The timing, therefore, is completely appropriate to look at the past, present, and future of the Academy. The title of this presentation was chosen after much thought. In the present health care environment, neither the Academy nor its members can survive as an isolated island. There is no question that isolation or insulation can be an excellent strategy for either an organization or an individual. In fact, in many respects this strategy was well used in the past. However, as medical practice and the field of physical medicine and rehabilitation have changed, so must our strategies for the future. When I first became a member of the Academy in the early 197Os, physical medicine and rehabilitation was far from a household word-in fact, it was a struggle at times to convince individuals in medicine that I was more than a “Doctor of Physical Therapy.” At that time in our history, isolation and insistence on physical medicine and rehabilitation as an important and separate medical entity was a necessity. This line of reasoning continued as I became involved with the Board of Governors nearly 15 years ago. Even then it made good sense for the specialty. The number of residency positions was limited and graduates of American medical schools were only beginning to consider physiatry as a career option. However, during the next decade significant changes occurred. The number of residency positions rapidly increased and American medical school graduates suddenly “discovered” our specialty. There are many reasons postulated for this phenomenon. The actual reason or reasons are not important; the end result is. What the field now has is a young and vital membership that is articulate and preparing itself to raise the level of awareness of physical medicine and rehabilitation. The growth and change in our membership could not have come at a better time because medicine as a whole has dramatically and fundamentally shifted during the past decade. Gone forever, I fear, is the day of the individual practitioner who could manage the business of a medical practice as a minor part of seeing and treating his patients. The “simple life” is being replaced by medicine as a business with mergers, consolidation, buy-outs, and strategic takeovers changing how we look at the still-enjoyable task of treating our patients. From the Bavlor Health Care Svstem. Dallas. TX Presented at- the 60th Annual’Assembly of the Amencan Academy of Physical Medicine and Rehabilitation. November 5, 1998, Seattle, WA. Reprint requests to Barry S. Smith, MD, Ted Landry Sports MedIcal Center, 411 North Washington Avenue, Suite 4000, Dallas, TX 75246.1776. 0 1999 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003.9993/99/X003-0001$3.00/O
To be successful in this new age, physiatrists and the Academy need a new strategy. The old strategy of isolation cannot work in this new environment of medicine. Medicine now works through partnerships. The practice of medicine tends to be multispecialty-based. Medicine is more and more delivered through service lines with multiple specialty input. Several different types of specialists seek confirmation of their competency to perform exactly the same procedure. If we as an Academy and as individual practitioners were to continue in the old isolationist mode we would quickly become a nonentity. The good news is that we as an Academy, as well as many of our members, have already begun to shift our emphasis. We have already initiated partnership arrangements organizationally and in clinical practice. More importantly, we have been extremely successful in these endeavors. For this success we can thank our predecessors. In their pursuit of isolationism for physical medicine and rehabilitation the early leaders of our specialty achieved their goal. At this point in time there is no question that physiatry is an integral part of organized medicine. There are many examples to demonstrate this, including the presence of physiatrists in national leadership roles such as the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties. However, the recognition of the specialty needs to be at a more fundamental level to benefit individual practitioners. Several years ago I had the opportunity to represent the AAPM&R at a national meeting of the American Heart Association. The interactions I had with the other attendees finally convinced me that we had arrived as a specialty. My name badge identified me as the Academy representative, without any other designation. I was certain I would spend the entire meeting explaining what physical medicine and rehabilitation was and exactly what I did as a specialist in this field. Much to my surprise and delight, such questions were never asked. Instead, as I introduced myself I was repeatedly asked what was the correct pronunciation of “physiatrist.” As I later reflected on these interactions, what was most remarkable was not the question itself, but the fact that nowhere on my name badge was the word “physiatrist!” These other professionals, most of them not physicians, were well enough acquainted with physical medicine and rehabilitation as a specialty to identify physiatrist as well. This single incident does not mean we can simply rest on our past successes.However, to me it does mean that we have already arrived. We can put away our defensive posture-that we need to justify our existence if someone asks for an explanation of our specialty. Rather, we need to believe that we have in fact arrived as a specialty and to act accordingly. As we enter into negotiations for potential partnerships or other arrangements, we should do it with the confidence of the established. No specialty is immune to the need to re-identify itself. The American College of Physicians is in the midst of a huge public relations campaign to help the public differentiate between an “intern” and an “internist.” To those of us in organized medicine this seems hardly to be an issue, but to the specialty of Internal Medicine it is enough of an issue that the specialty is considering a name change to increase its public recognition. Reflecting on this change in attitude toward our specialty, and Arch
Phys
Med
Rehabil
Vol 80, March
1999
242
ACADEMY
PRESIDENTIAL
on the need to actively partner with others, the Academy is increasingly interfacing with external partners. Establishing practice guidelines for the specialty may be the prime example of this changing approach to external partnering. When the Academy first decided to develop guidelines, they were going to be completely developed by the Academy for Academy members. Every other specialty began in much the same mode, so that we now have almost uncountable numbers of guidelines developed by different groups for the same clinical problem. The guidelines have been extremely expensive for each organization to produce. More critically, because there are so many on the same topic, none of them are widely enough accepted to be of any real value to practicing physicians. Whenever there is a question as to the appropriateness of a practice activity, competing guidelines serve only to confuse the practice issues, not to resolve them. The Academy position now is to work with other organizations within medicine to mutually develop guidelines or to endorse appropriate guidelines developed by others. We now have guidelines that move across these artificial barriers, and the patients we serve can now consistently receive the best clinical care. The Academy has developed active working groups with several specialties. In the era of isolationism such groups would never have been considered. However, with the changing focus in medicine, these have been extremely successful. In 1998 there was a potential problem with referring patients for electrodiagnostic testing. The Academy and its membership responded extremely well. However, we had already established good working relations with the specialty of neurology and the American Association of Electrodiagnostic Medicine. With them, we were able to coordinate a much broader response that successfully averted the potential loss of patient referral for all electrodiagnosticians. As medicine has developed, added qualifications in areas of subspecialization have become a frequently discussed topic. When the Academy approach to issues was one based in isolationism, opportunities for physiatrists to obtain added qualifications were lost. The physiatric organizations, including the Academy, now approach the certification of added qualifications cohesively with other groups in organized medicine. Because of this approach, physiatrists can now receive this designation in spinal cord injury medicine. Soon this opportunity will be available in pain management and, hopefully, pediatric rehabilitation. Working in concert with others-not continued isolationism-made this possible. The most important partnership the Academy or any other professional organization can make is with its membership. As early as the 1980s the Academy, under the guidance of Erwin Gonzalez, recognized the need to partner with state societies of physical medicine and rehabilitation. This partnership originally was the Liaison Council of PM&R Societies; it has become the Council of State Society Presidents. The end
Arch
Phys
Med
Rehabil
Vol 80, March
1999
ADDRESS,
Smith
result-not the name-is important. We are developing an effective tool to keep the flow of critical information moving between the states and the national office, and an effective vehicle to mount legislative or other activity from all our members when needed. The clinical practice example of partnering is the establishment and strengthening of the Physiatric Association of Spine, Sports and Occupational Rehabilitation (PASSOR) within the structure of the Academy. The members recognized the need to strengthen AAPM&R musculoskeletal focus. The Academy recognized the need to keep all our members together to potentiate the influence of Physiatry. Together, an alliance was built that strengthens all of physical medicine and rehabilitation and benefits all of the members. The most significant undertaking the Academy has ever initiated, certainly from a fiscal standpoint, is the PM&R Awareness Initiative. This program responds to innumerable requests from members for the Academy to help them market themselves and their practices. Marketing the specialty has long been a primary goal for the Academy. For many years only the persistent marketing vision of Joachim Opitz kept this effort alive. Then the potential cost and the complexity of the task slowed the effort. Finally a plan evolved and a dedicated work group led by Kris Ragnarsson brought the project to fruition. For the first time, members have a broad variety of tools to use in marketing themselves and the specialty. These include a comprehensive manual entitled a “Guide to Practice Marketing,” which covers multiple areas of marketing, including public relations and community outreach. Two brochures were developed to emphasize the value of physiatric practice, one for managed care executives and one for use with primary care physicians. An MC0 Resource Kit was developed to be distributed to human resource directors and managed care medical directors. Because many Academy members do not have the resources to develop complex slide presentations, a general educational slide program, with an accompanying script and handout suggestions, was developed. This presentation is designed to be easily individualized by each member. New approaches to the practice of medicine. Partnering rather than isolationism. Marketing initiatives. What else may happen and what does the future hold for physical medicine and rehabilitation as the 21st century and the new millenium arrive? None of us has a crystal ball to predict the future. However, I feel extremely positive about the future of our specialty. The growing pains and the fear of extinction of the specialty are in the past. Physical medicine and rehabilitation is an important and ongoing player in the areas of musculoskeletal and rehabilitation medicine. Physiatrists and the physiatric organizations to which they belong will continue to be leaders in the arenas of clinical care for our patients, education of practitioners in the field of PM&R, and advocacy for the field and the persons we serve.
ACADEMY
PRESIDENTIAL
No Organization
ADDRESS
Is an Island Unto Itself
Barry S. Smith, MD HE OPENING SESSION of the Annual Assembly allows T each of us who have been fortunate enough to become the President of the American Academy of Physical Medicine and Rehabilitation the opportunity to express ourselves as we complete our year of service to this organization. In our addresses we attempt to state beliefs or visions, either ours personally or for the Academy. The Annual Assembly in this year of 1998 affords a unique opportunity to look both to the past and to the future. This is the 60th anniversary of the Academy, and it is occurring near the end of a century and as we approach a new millenium. The timing, therefore, is completely appropriate to look at the past, present, and future of the Academy. The title of this presentation was chosen after much thought. In the present health care environment, neither the Academy nor its members can survive as an isolated island. There is no question that isolation or insulation can be an excellent strategy for either an organization or an individual. In fact, in many respects this strategy was well used in the past. However, as medical practice and the field of physical medicine and rehabilitation have changed, so must our strategies for the future. When I first became a member of the Academy in the early 197Os, physical medicine and rehabilitation was far from a household word-in fact, it was a struggle at times to convince individuals in medicine that I was more than a “Doctor of Physical Therapy.” At that time in our history, isolation and insistence on physical medicine and rehabilitation as an important and separate medical entity was a necessity. This line of reasoning continued as I became involved with the Board of Governors nearly 15 years ago. Even then it made good sense for the specialty. The number of residency positions was limited and graduates of American medical schools were only beginning to consider physiatry as a career option. However, during the next decade significant changes occurred. The number of residency positions rapidly increased and American medical school graduates suddenly “discovered” our specialty. There are many reasons postulated for this phenomenon. The actual reason or reasons are not important; the end result is. What the field now has is a young and vital membership that is articulate and preparing itself to raise the level of awareness of physical medicine and rehabilitation. The growth and change in our membership could not have come at a better time because medicine as a whole has dramatically and fundamentally shifted during the past decade. Gone forever, I fear, is the day of the individual practitioner who could manage the business of a medical practice as a minor part of seeing and treating his patients. The “simple life” is being replaced by medicine as a business with mergers, consolidation, buy-outs, and strategic takeovers changing how we look at the still-enjoyable task of treating our patients. From the Bavlor Health Care Svstem. Dallas. TX Presented at- the 60th Annual’Assembly of the Amencan Academy of Physical Medicine and Rehabilitation. November 5, 1998, Seattle, WA. Reprint requests to Barry S. Smith, MD, Ted Landry Sports MedIcal Center, 411 North Washington Avenue, Suite 4000, Dallas, TX 75246.1776. 0 1999 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003.9993/99/X003-0001$3.00/O
To be successful in this new age, physiatrists and the Academy need a new strategy. The old strategy of isolation cannot work in this new environment of medicine. Medicine now works through partnerships. The practice of medicine tends to be multispecialty-based. Medicine is more and more delivered through service lines with multiple specialty input. Several different types of specialists seek confirmation of their competency to perform exactly the same procedure. If we as an Academy and as individual practitioners were to continue in the old isolationist mode we would quickly become a nonentity. The good news is that we as an Academy, as well as many of our members, have already begun to shift our emphasis. We have already initiated partnership arrangements organizationally and in clinical practice. More importantly, we have been extremely successful in these endeavors. For this success we can thank our predecessors. In their pursuit of isolationism for physical medicine and rehabilitation the early leaders of our specialty achieved their goal. At this point in time there is no question that physiatry is an integral part of organized medicine. There are many examples to demonstrate this, including the presence of physiatrists in national leadership roles such as the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties. However, the recognition of the specialty needs to be at a more fundamental level to benefit individual practitioners. Several years ago I had the opportunity to represent the AAPM&R at a national meeting of the American Heart Association. The interactions I had with the other attendees finally convinced me that we had arrived as a specialty. My name badge identified me as the Academy representative, without any other designation. I was certain I would spend the entire meeting explaining what physical medicine and rehabilitation was and exactly what I did as a specialist in this field. Much to my surprise and delight, such questions were never asked. Instead, as I introduced myself I was repeatedly asked what was the correct pronunciation of “physiatrist.” As I later reflected on these interactions, what was most remarkable was not the question itself, but the fact that nowhere on my name badge was the word “physiatrist!” These other professionals, most of them not physicians, were well enough acquainted with physical medicine and rehabilitation as a specialty to identify physiatrist as well. This single incident does not mean we can simply rest on our past successes.However, to me it does mean that we have already arrived. We can put away our defensive posture-that we need to justify our existence if someone asks for an explanation of our specialty. Rather, we need to believe that we have in fact arrived as a specialty and to act accordingly. As we enter into negotiations for potential partnerships or other arrangements, we should do it with the confidence of the established. No specialty is immune to the need to re-identify itself. The American College of Physicians is in the midst of a huge public relations campaign to help the public differentiate between an “intern” and an “internist.” To those of us in organized medicine this seems hardly to be an issue, but to the specialty of Internal Medicine it is enough of an issue that the specialty is considering a name change to increase its public recognition. Reflecting on this change in attitude toward our specialty, and Arch
Phys
Med
Rehabil
Vol 80, March
1999
242
ACADEMY
PRESIDENTIAL
on the need to actively partner with others, the Academy is increasingly interfacing with external partners. Establishing practice guidelines for the specialty may be the prime example of this changing approach to external partnering. When the Academy first decided to develop guidelines, they were going to be completely developed by the Academy for Academy members. Every other specialty began in much the same mode, so that we now have almost uncountable numbers of guidelines developed by different groups for the same clinical problem. The guidelines have been extremely expensive for each organization to produce. More critically, because there are so many on the same topic, none of them are widely enough accepted to be of any real value to practicing physicians. Whenever there is a question as to the appropriateness of a practice activity, competing guidelines serve only to confuse the practice issues, not to resolve them. The Academy position now is to work with other organizations within medicine to mutually develop guidelines or to endorse appropriate guidelines developed by others. We now have guidelines that move across these artificial barriers, and the patients we serve can now consistently receive the best clinical care. The Academy has developed active working groups with several specialties. In the era of isolationism such groups would never have been considered. However, with the changing focus in medicine, these have been extremely successful. In 1998 there was a potential problem with referring patients for electrodiagnostic testing. The Academy and its membership responded extremely well. However, we had already established good working relations with the specialty of neurology and the American Association of Electrodiagnostic Medicine. With them, we were able to coordinate a much broader response that successfully averted the potential loss of patient referral for all electrodiagnosticians. As medicine has developed, added qualifications in areas of subspecialization have become a frequently discussed topic. When the Academy approach to issues was one based in isolationism, opportunities for physiatrists to obtain added qualifications were lost. The physiatric organizations, including the Academy, now approach the certification of added qualifications cohesively with other groups in organized medicine. Because of this approach, physiatrists can now receive this designation in spinal cord injury medicine. Soon this opportunity will be available in pain management and, hopefully, pediatric rehabilitation. Working in concert with others-not continued isolationism-made this possible. The most important partnership the Academy or any other professional organization can make is with its membership. As early as the 1980s the Academy, under the guidance of Erwin Gonzalez, recognized the need to partner with state societies of physical medicine and rehabilitation. This partnership originally was the Liaison Council of PM&R Societies; it has become the Council of State Society Presidents. The end
Arch
Phys
Med
Rehabil
Vol 80, March
1999
ADDRESS,
Smith
result-not the name-is important. We are developing an effective tool to keep the flow of critical information moving between the states and the national office, and an effective vehicle to mount legislative or other activity from all our members when needed. The clinical practice example of partnering is the establishment and strengthening of the Physiatric Association of Spine, Sports and Occupational Rehabilitation (PASSOR) within the structure of the Academy. The members recognized the need to strengthen AAPM&R musculoskeletal focus. The Academy recognized the need to keep all our members together to potentiate the influence of Physiatry. Together, an alliance was built that strengthens all of physical medicine and rehabilitation and benefits all of the members. The most significant undertaking the Academy has ever initiated, certainly from a fiscal standpoint, is the PM&R Awareness Initiative. This program responds to innumerable requests from members for the Academy to help them market themselves and their practices. Marketing the specialty has long been a primary goal for the Academy. For many years only the persistent marketing vision of Joachim Opitz kept this effort alive. Then the potential cost and the complexity of the task slowed the effort. Finally a plan evolved and a dedicated work group led by Kris Ragnarsson brought the project to fruition. For the first time, members have a broad variety of tools to use in marketing themselves and the specialty. These include a comprehensive manual entitled a “Guide to Practice Marketing,” which covers multiple areas of marketing, including public relations and community outreach. Two brochures were developed to emphasize the value of physiatric practice, one for managed care executives and one for use with primary care physicians. An MC0 Resource Kit was developed to be distributed to human resource directors and managed care medical directors. Because many Academy members do not have the resources to develop complex slide presentations, a general educational slide program, with an accompanying script and handout suggestions, was developed. This presentation is designed to be easily individualized by each member. New approaches to the practice of medicine. Partnering rather than isolationism. Marketing initiatives. What else may happen and what does the future hold for physical medicine and rehabilitation as the 21st century and the new millenium arrive? None of us has a crystal ball to predict the future. However, I feel extremely positive about the future of our specialty. The growing pains and the fear of extinction of the specialty are in the past. Physical medicine and rehabilitation is an important and ongoing player in the areas of musculoskeletal and rehabilitation medicine. Physiatrists and the physiatric organizations to which they belong will continue to be leaders in the arenas of clinical care for our patients, education of practitioners in the field of PM&R, and advocacy for the field and the persons we serve.