In a recent scientific journal editorial, the author points out that within the specialty of Physical Medicine and Rehabilitation (PM&R), maintaining patients’ health and wellness might be a niche for physicians. Given that PM&R is my specialty, I have to agree. It is particularly suited to examine the entire picture of one’s well-being by offering an approach that is unique in medical care.

PM&R (also called physiatry) is a field often overlooked in medicine. For those who are not familiar with it, it covers a broad spectrum of conditions including: chronic pain, spinal cord injury, traumatic brain injury, stroke, joint replacement, multiple sclerosis, Parkinson’s, amputees, burn and cancer, women’s health, cardiac and pulmonary, and electrodiagnostic medicine. It also incorporates holistic approaches perhaps more than any other field, with many physiatrists receiving training in acupuncture and other alternative medical techniques. Because patients seek physiatrists’ care only after their acute illnesses are managed, the field does not garner the attention that typically goes to emergency care, cardiology, orthopedics, or any number of other more high-profile specialties. However, for those who have ever required rehabilitation, they will tell you first-hand how critical it is. PM&R is the medicine of functional ability, and just as importantly, how patients transition into the community. With offerings that range from physical and occupational therapy, to speech, vocational, and swallow therapy, PM&R is there to assist the disabled in the true sense of the word. It is a model within medicine because it thrives on a multi-disciplinary approach which always considers multiple aspects of a patient’s well-being. While other specialties do their work in “teams”, their approach does not entail the sort of all-encompassing view physiatrists adopt.

But that is where the discussion gets skewed. Here is a chief editor of a PM&R journal pointing out that monitoring patients’ health and wellness may be a niche market for clinicians. His sentiment, while accurate, is surprising on many levels. Aren’t all physicians supposed to be looking out for patients’ well-being already? Can wellness be a niche when the system as a whole should have a dedicated framework for approaching this issue? Unfortunately, medical care in the US focuses almost exclusively on disease management and more recently on prevention. There is in fact very little focus on wellness or well-being.

Surprising? It shouldn’t be. Despite the tremendous opportunity our health care system offers, critics continuously point out the poor outcomes data we churn out annually. Additionally, for those who have followed the discussion surrounding well-being in our other postings, this information should resonate clearly. It is not only employers who are faced with a dearth of understanding of what constitutes well-being, but providers as well. There is very little in medical school training about notions of well-being and how it might impact medical care. Patient satisfaction for example, which has consistently been shown to correlate highly with multiple aspects of patient outcomes, is not mentioned at all during training. And while hospitals have instituted wellness programs for their employees to stay aligned with employers in other industries, nearly all have ignored doing the same for their chief customer: patients.

A recent article in The Washington Post (Lovenheim, 11/10/09) discusses how many medical schools are changing their focus. Instead of anatomy, students now take classes on the physician/patient relationship, communicating with patients, and social and cultural issues in health care. George Washington University students were brought to Capitol Hill to learn more about health policy, and Johns Hopkins is revamping its curriculum based on the imminent growth of personalized medicine. Medical schools are trying to keep pace, as are some hospitals. A national licensing exam was instituted a few years ago that requires medical students to examine patient actors to assess communication skills and the Accreditation Council for Graduate Medical Education has included communication and patient care as two of the six core competencies of residency training.  But is this shift enough?

The notion of well-being permeates many different levels of our society and arguably has a profound impact on health outcomes. By defining what well-being means and understanding its role in health care especially, we may just be able to drive dramatic effects on patient care. While the editor of the PM&R journal has pointed out a tremendous niche for clinicians, we can only hope that it is quickly over-saturated.

Tags: George Washington University, health, Health care, Medical school, Medicine, Physical Medicine and Rehabilitation, Traumatic brain injury, Washington Post, well-being, wellbeing

Posted by Doug Elwood, M.D. on 11/30/09. Categories: Blog. You can follow any responses to this entry through the RSS 2.0 feed.