THE PAST

One might inquire what a history and philosophical chapter is doing in an evidence-based clinical textbook. Interventional spine procedures by physiatrists at first glance seem simply to be an outgrowth of physical medicine, a clinical right turn justified by new information similar to other changes in medical practice such as interventional cardiology. But the role of the practitioner is so fundamentally changed from previous roles that a deeper inquiry is invited. How do such striking ‘about-faces’ occur in medicine? What and who promotes these changes and how are they accomplished? After all, a hospital-based practitioner can’t simply announce one day that he or she is going to have entry to a surgical suite or intervention room and do new procedures. The author is grateful to the many early members of the Physiatric Association of Spine Sport and Occupational Rehabilitation (PASSOR) who were willing to e-mail to the author their observations regarding how they became involved is this movement, who influenced them, and in which directions they believe we are evolving.

Most of organized medicine, including its Boards, Academies and educational hierarchy, justify their existence by including words such as ‘in the public interest …’ in their constitution or bylaws preamble. None should believe that such baser needs such as ego, power, control, and economic well-being and keeping a practice away from ‘the other guy’ do not play a role as well. The trick to good organizational management and maintenance of the voluntary system of medical accreditation is to be sure the balance favors public good a great deal more than the practitioner benefit.

The development of interventional physiatry represents a model study of how change is reasonably brought about in medical practice. If one reviews the history of the practice of medicine in the United States since Flexner’s report,¹ the complex story of organized medicine is found to be the string in the supersaturated sugar solution (the great mix of knowledge, attitudes, and practices) allowing the formation of rock candy (the roles of the various medical and surgical specialties). An approach through organized medical channels is the ‘way’ to get desired changes. Change does not occur quickly, nor particularly smoothly; however, the system seems to work. Perseverance pays. Such has been the case for interventional physiatry.

Osler in medicine, and Halstead and others in surgery are names known by every internist and surgeon. These pioneers opined that 4 years of matriculation through even the best medical school curriculum was inadequate to teach the volume and complexity of knowledge, skills, and behaviors required to properly care for patients with significant illness. Postgraduate medical education at the bedside was required, and the development of a capacity for life-long professional learning.

During the first 20 years of the twentieth century there was no such thing as a physical medicine and rehabilitation doctor. World War One, however, produced sufficient casualties, many with musculoskeletal injuries, that would become chronic and which seemed to improve when treated with physical modalities including hydrotherapy and therapeutic exercise and newly harnessed portions of the electromagnetic spectrum. With the lead of the American Medical Association in the 1915–21 time frame, a group of physical modality experts were called together to see how more physicians might learn about and put to use these procedures. The AMA Board of Trustees approved this group, called the American Congress of Physical Therapy, in September 1921. It was not to be the start of a new specialty, but rather a task force to enhance knowledge and skills. It consisted of physicians from medicine, most of whom were attached to academic centers and who had studied and advocated for these methods. The AMA had previously and subsequently stimulated and assisted the creation of the American College of Surgeons (ACS) and the American College of Physicians (ACP) and several surgical and medical specialty organizations. With the American Association of Medical Colleges (AAMC) and the Association of Teaching Hospitals, the AMA, ACP, and ACS, the idea of credentialing individuals who were willing to subject themselves to additional postgraduate education, training, and experience and who were willing to put their knowledge and skills to a test, thereby identifying properly trained ‘specialists’ for the public. The medical schools came under the supervision of the Liaison Council for Medical Education (LCME), the residencies under residency review committees (RRCs) appointed jointly by the AMA section councils and specialty societies and supervised by the Accreditation Council on Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS), continuing education led by the Council on Medical Specialty Societies (CMSS). The various liaison groups had representation from practitioners, academicians, hospitals, boards, and medical and surgical academies. When federal dollars became prominent in support of medical education and practice, government representatives were added, but control was always in the hands of physician volunteers who were either elected by or appointed by their peers to represent them.

In its earliest days practitioners of physical medicine often shared an interest in the newly developed area of ionizing radiation. In 1923, the American College of Radiology and Physiotherapy became the first physical medicine society. As radiology established itself as a separate discipline, the organization’s name was changed to drop radiology; however, the first journal was titled the Archives of Physical Therapy, X-ray and Radium. In 1930, the organization became the American Congress of Physical Therapy and in 1945, as the practice of physical therapy became its own discipline, the name changed to the American Congress of Physical Medicine. By 1954, the World War Two-developed team concept of care, espoused by Howard Rusk and George Deaver, caused another name change to Physical Medicine and Rehabilitation. By 1967, the ‘team concept of rehabilitation’ devotees were of sufficient number to cause the name to change to the American Congress of Rehabilitation Medicine. Their journal became the Archives of Physical Medicine and Rehabilitation. Upon action from an AMA advisory council on medical specialties, on June 6, 1947, eleven physiatrists became the first American Board of Physical Medicine with Krusen as its first chairman and Zeiter as vice-chairman. A few physiatrists were ‘grandfathered’ and a total of 103 became the first listed Board Diplomats. In 1949 the board name was changed to the American Board of Physical Medicine and Rehabilitation following the trend towards rehabilitation.

The group that was to become the American Academy of Physical Medicine and Rehabilitation (PM&R) began in 1938–39 as an invitation-only membership of 42 physical therapy physicians with an intent of limiting membership to 100 physicians. After 1952, all Diplomats of the American Board of Physical Medicine and Rehabilitation were invited to become members. In 1957, a conference was held to determine the proper roles of the Academy versus the American Congress. The Congress was to control the journal, to provide interdisciplinary rehabilitation education, and to reach out to nonphysiatrist physicians interested in the field. The Academy was to bring their member physiatrists into closer collaboration with other physician peers and concentrate on physiatric education and policy. The Academy was to represent the field in the AMA House of Delegates. Later, after considerable negotiation, the Archives of PM&R ownership were split by the Congress with the Academy for a purchase price of ‘$1.00 and considerations.’ Editorial Boards represented each organization under an editor-in-chief. As the Academy grew, and as the various allied professions became more independent with policy interests different at times from physicians, physiatric membership in the Congress declined. Several attempts were made to work out ways to stay allied and share a common central office but a split was inevitable. The Congress now is independent of the Academy, smaller in membership and has refocused itself to interdisciplinary rehabilitation research. The Council of Academic Societies (CAS) of the Association of American Medical Colleges in 1967 rejected the American Academy of Physical Medicine and Rehabilitation as too broadly based to be a constituent member but at the same time recognized the newly formed Association of Academic Physiatrists (AAP) to represent undergraduate and graduate medical education interests and academic policy.

The history of the specialty of Physical Medicine and Rehabilitation is covered in detail elsewhere and should be reviewed for a more complete story.^2–6 Elkins, Knapp, Bennett, Bierman, Kovacs, Molander, Coulter, Zeiter, Krusen Ewerhardt and others were among the originators of the field followed by Rusk, Deaver, Johnson, Lehman, Kottke, Stillwell and many more than can be mentioned here. Review will be rewarding to observe how a small group of dedicated physicians gave much volunteer time and attention to the multiple facets necessary for growth of a medical specialty.

One should appreciate that what began as a ‘physical medicine’-oriented body of knowledge transitioned to a medical rehabilitation orientation over time. Physical medicine was never ‘lost;’ it was simply less visible with the overriding mass appeal of rehabilitation as popularized by Rusk.⁷ New York philanthropist Bernard Baruch played a major role in stimulating development of 12 departments that matriculated nearly 60 early physiatric pioneers. Baruch convinced President Truman of the field’s contribution to the war and postwar effort. The President ordered military medical authorities to embrace the field. Civilian interest followed. Large infusions of federal dollars from the Medicare program followed. During the DeBakey era, heart disease and stroke held the top-tiered research support position. This funding resulted in increased medical rehabilitation demands and funding at a time of virtual nonfunding for musculoskeletal disorders and research. These currents influenced the practitioners and their representatives in the American Academy of Physical Medicine and Rehabilitation. Those physicians with a more physical medicine orientation often complained of inadequate attention and resource sharing in the Academy. In general, the physical medicine oriented physiatrists gravitated towards care of more acute neuro-musculo-skeletal disorders including ever more ubiquitous spine related pain. In the military, the training programs focused on physical medicine, with rehabilitation to occur in the Veterans Administration system. In this setting, and in the growing private musculoskeletal practice setting, the physiatrist saw acute patients and often provided full diagnostic and therapeutic care, referring to other specialties as was appropriate. This conflicted with the rehabilitation model in which practitioners were describing their domain as ‘the third phase of medicine after preventive medicine and acute care.’ In the latter paradigm, the physiatrist did not have access to the patient except upon referral from a physician or surgeon who were the primary practitioners.

In preparation of this chapter, a call was sent to founding PASSOR members to identify the influences upon them to become members. Perhaps the most frequently cited was the desire to become a primary practitioner for musculoskeletal patients. They were influenced by orthopedists such as James Cyriax, Arthur White, John Fromoyer, Malcolm Pope, W.H. Kirkaldy-Willis, and Alf Nachemson and sometimes encouraged to become ‘nonoperative orthopedists’ in lieu of physiatrists. They were also influenced by independent minded physiatrists whose credentials in physical medicine were rich and who were expert in use of modalities and therapeutic exercise, clinical kinesiology, and the newly developing field of electrodiagnostic medicine such as V. Lieberson, Carl Granger, Justus Lehman, Ernest Johnson, Myron Laban, Erwin Gonzalez, Ian MacLean, Joe Honet and others. Henry Betts was identified as a facilitator sympathetic to growth in this arena. Newer generations of PASSOR members were greatly influenced by Jeffrey and Joel Saal and their associate Stan Herring. These physiatrists were often themselves sportsmen whose interests gravitated in this direction. To this group add those physiatrists whose practices included large numbers of injured workmen. Many of these patients suffered spine-related pain disorders. The musculoskeletal physiatrists included also those who followed the work of Janet Travell and Dave Simons in dealing with the clinical entity of myofascial pain syndrome and those whose interests gravitated to arthritis and related disorders. Many of these physicians tended to feel that the Archives of Physical Medicine and Rehabilitation, especially those issues sponsored by the American Congress of Rehabilitation Medicine, did not adequately represent their spine and musculoskeletal interests and did not believe the Archives was well regarded by spine and sports peers in medicine. The policy issues facing the main field of rehabilitation, which were primarily government regulatory-related, were of little concern to the physical medicine practitioner who was not practicing in rehabilitation facilities but was more often office or clinic based. Furthermore, the educational offerings of the Academy were felt to slight the need for both basic and advanced material from the musculoskeletal area, especially spine and sport, and not to pay adequate attention to the office practice needs of these physiatrists. The earliest and common practice model, which continues today, was for the physiatrist to associate with an orthopedist or orthopedic group practice, becoming the member who did not perform surgery, but attended to diagnostics and postoperative care. Government and insurance bodies tended to ‘bundle’ preoperative care, surgery, and limited postoperative care into one standard surgical fee. The surgeon now had a financial incentive to pass on care to another specialist. Furthermoe, additional members in a group practice made investment in practice-owned diagnostic imaging equipment and laboratories inviting and increased the frequency of use of the equipment. As physiatrists became competent in interventional spine procedures, more struck out on their own or became part of single-specialty (physiatric spine medicine) practice groups. Several academic programs became involved. Orthopedists and family practitioners laid claim to sports medicine, although several physiatrists have become professional and school team physicians and are highly regarded for their work. Physiatrists have become increasingly attractive to insurers and re-insurers as the physicians of choice for industrial musculoskeletal injuries and post-trauma soft tissue injuries. These physicians offer thorough history and physical examination, astute diagnostic capabilities, nonsurgical (read less expensive) remediative and rehabilitative care, ability to collaborate when surgery is indicated, and disability evaluation and management all in one place. The capacity to perform electromyography and diagnostic and therapeutic blocks in carefully selected patients was an added benefit.

During the 1980s the Academy of PM&R attempted to address these musculoskeletal and related issues by permitting the development of special interest groups (SIGs) which became responsible for developing education appropriate to their interest and promoting policy concerns to Academy Board attention. During the annual meeting, the Academy met the first part of a week, the Congress the second part, with the middle weekday for supposed integrated blend. Time and organizational collaboration was inadequate to meet the needs of either party and disenchantment grew. There was even consideration of development of a new group outside of the Academy of PM&R to represent the interests of these musculoskeletal-oriented physiatrists.

At the same time, the Academy Board, and in fact much of organized medicine, was involved in a great debate regarding subspecialization and the credentialing of subspecialists. To the degree that groups identified special added competence, the issues of territoriality appeared, i.e. limitation to one kind of practitioner or open to members of vorious Boards of Specialty. Added to this were issues of curriculum content definition and development of a critical mass of expert educators and clinical facilities to achieve the educational standards. Would specialization prevent the general Diplomat from practice in the defined area? Would that in effect drive out competition and be inflationary? Would subspecialty educational offerings be available to all (generally making the offerings entry level) or be at advanced level, good for the specialist but beyond benefit to the generalist? Would an added credential become a requirement for hospitals and certifying organizations to allow privileges or access to practitioners or for courts to recognize expertise? The Academy (and medicine) resolved these issues differently in various areas such as pediatric rehabilitation, electrodiagnostic medicine, spinal cord injury, and head injury rehabilitation.

There was waxing and waning of support for the musculoskeletal specialization at the Academy Board level depending on the relative representation of rehabilitation primary versus physical medicine primary practitioners on the Board. Quick fixes allowing SIGs greater access to program content met with resistance from program committee members who felt their control and ability to meet their responsibilities challenged. At the same time, division over ownership and editorial control of the Archives of PM&R raged on at a time when the two organizations were growing ever more apart in their aspirations and needs.