You see, for more than 20 years, there were no physical medicine and rehabilitation (PM&R) specialists in our program at Jackson Memorial, and pretty much all of neurological rehabilitation was controlled by neurologists. When the PM&R physicians were introduced to our institution, the administrative and medical leadership allowed the development of a very toxic and competitive environment to thrive instead of uniting the PM&R program with the established neurological rehabilitation program. Simply bringing in a new specialist program without consulting the folks running the program in the first place created an all-out war between the neurology and the PM&R departments. The leadership did not take the time to understand this conflict between PM&R physicians and neurologists, which in my opinion contributed to the demise of the program as we knew it. Several of you around the country may relate to this issue. Hospital administrators and university leaders fail to understand the need for a unified interdisciplinary approach to this complex critical science, whereby both specialists working side by side would have clearly improved the program, as there was enough business for all parties to share.
This issue has been a source of chaos in our business. Unfortunately, a silent divide exists between certain specialties in medicine. I can only speak about that between the PM&R and neurologists treating TBI/concussion because I have lived it and observed similar ones nationally. This kind of political divide in medicine is driven by economics and the desire for control and political power. I hear my neurology colleagues often say that we should be the ones treating brain injury. We know more about the brain than anyone else. The evolution of care for persons with brain injury treatment and rehabilitation came out of major military conflicts where orthopedics and neurosurgery initially had the responsibility of brain and spine acute care and rehabilitation. They abdicated the responsibility of rehabilitation to the emerging field of PM&R. Neurologist, while heavily involved in the science of brain injury, took a long time to get engaged in the care of patients with brain injury in an organized manner. Most neurology training programs do not offer training in TBI and concussion. PM&R, on the other hand, has reorganized the field of brain rehabilitation by introducing the interdisciplinary team approach together with the measures of outcomes, which became their claim to fame at the national level. There are ongoing formidable studies in the field, which are transforming lives, being conducted by interdisciplinary teams of specialists that include neurologists, psychiatrists, PM&R physicians, neurosurgeons, primary care physicians, orthopedic surgeons, neuropsychologists, and other specialists and therapists.
I applaud the fact that the PM&R establishment has done a much better job than our neurology colleagues in providing leadership in brain injury rehabilitation research, program development and management, evaluation scales, and tools. Moreover, it has influenced the political establishment of state and local governments in ways neurologists could not.
Passionate chairpersons in PM&R have taken on this movement with fervor, leading to their success and dominance. On the contrary, neurology leadership has not taken on this issue in a manner that would have allowed them to thrive. Neurologists often see themselves as better prepared to handle some of the issues in TBI/concussions, but in terms of providing care, most neurologists have taken the view that this kind of patient is for another specialty to handle. Irrespective of the side of this issue, we all have biases, but we also have certain strengths and weaknesses from our training and how we are cultured at the institutions where we were trained. Also, let’s not forget our own worldviews.
This single issue has stymied the development of our science and program and is like cancer in the development of programs in neurological rehabilitation and brain injury. Neurologists who study neuro-behavior, neurophysiology, and the neuroscience of recovery are more equipped in those areas through training. PM&R specialists are more equipped in their training on all aspects of physical medicine and rehabilitation. Neurologists can clearly be trained in physical medicine, and PM&R specialists can be trained in neuro-behavior and neuro-cognition. This divide is not only evident at the hospital and university levels but also in our national organizations and in how the government and other political entities treat our specialties from a funding standpoint. The most successful programs around the countries are those where the disciplines collaborate.
Yes, the consumers and other stakeholders need to know this. There are silent wars going on in medicine for who should treat you and with what treatments. Everyone is weighing in, and if you have enough organizational support and will, you win.
Even as a very recent specialty group with a fraction of the members compared to neurologists, PM&R is well organized to address rehabilitation issues. I cannot tell you that I am not without fault in being so critical about my neurological colleagues, but this is the big picture. Allow me to generalize for a moment: I find most neurologists are traditionalists, sometimes unwilling to think out of the box at times. We as neurologists have sometimes set standards that we can’t even keep. We have forgotten the fundamentals of financial sustainability and sensible policy: the administration of our facilities holding the purse strings, our politicians, and the influence of populations of persons that we care for.
Internal politics are prevalent in various fields. I will get on the soapbox to say this, “Stroke has become synonymous with neurology.” It is sad to say that this issue is present in just about every training program. It is stroke neurology, and more stroke neurology, only to be matched by neuro-hospitalist and critical care neurology. Follow the money! Now we are complaining that over the years, psychiatrists have taken over dementia from the behavioral neurologists, and the neuro-radiologists and neurosurgeons have taken over vascular interventional procedures and reading MRIs. We also mourn that the PM&Rs are now taking over the electrical studies of muscles and nerves.
Just look at the Medicare fee schedule and see who is being paid the most. Surgeons and medical physicians who do procedures rank as the highest-paid. Surgeons perform surgical procedures in medicine that take under an hour, and I as a neurologist see a patient with complex brain injury, educate the family, and let’s not even talk about documentation, which takes a considerable amount of time compared to documentation from other specialists. For the same amount of time spent, doing a neurological consult, someone doing a procedure will be paid more than 3–4 times what I will generate in income in some cases. So, you ask the question, why have we not focused on brain injury as a business in health care? Does it not pay enough or pay well? Mental health is now classified as among the least reimbursable disorders in medicine, and that is where brain injury fits. In fact, my neurology and PM&R colleagues have relegated the treatment of neuro-behavior to psychiatrists, who like most neurologists, generally get little or no training in concussions and TBI. No wonder we use more psychotropic drugs to manage brain injury, often making the patient worse and potentially retarding recovery. And yes, these issues of conflict in our field are affecting the outcomes of our brain injury patients. The programs that work best in rehabilitation have an interdisciplinary working relationship between PM&R, psychiatry, neurosurgery, neurology, and others. The leadership in PM&R, psychiatry, and neurology are not communicating at a level that is sensible. I will tell you that this has filtered down to the residents in all of our specialties, and I hope that the next generation of leadership can tackle this issue head-on.
Still on the soapbox!
Here is another issue that we have to face from time to time. Today, the field of neuropsychology is growing, and we are encouraged by the added number of neuropsychologists in the field of brain injury. If you want to get a neuropsychological test performed on a patient, you can find many neuropsychologists ready to test but very few available to treat. A neuropsychologist can spend 4–8 hours testing and generate between $1500–$8000 in the USA. The same neuropsychologists administering treatment for an hour with a patient can barely generate $80–$100. It is no wonder the field of neurocognitive therapy treatment is not developed to match the level of demand that exists in society. In fact, the purists in our industry go further by saying that cognitive therapy does not work. While we need further studies on the subject, I know that TBI/concussion patients improved with neurocognitive therapy.