Okay, welcome. We'll get started to be on time. Thanks for coming. This was not an easy room to find, so it's a real commitment to being here, not to mention the scores of people who are watching this online, hundreds maybe, we don't know. So welcome. I'm Carolyn Kinney. I'm the Executive Director of the American Board of PM&R, and I'll be one of the speakers today along with Dr. Sunil Sabharwal and Dr. David Pruitt. I'm just going to introduce all three of us briefly. So I kind of already gave what my role is officially with the board. I'm also on the staff at Mayo Clinic in Arizona, and I think that's pretty much me in a nutshell. Dr. Sabharwal is an Associate Professor of Physical Medicine and Rehab at Harvard Medical School. He's at the Boston VA, and he runs Spinal Cord Injury Service there. He's also a former Director of the American Board of PM&R. And David Pruitt is a Professor of Pediatrics and Rehabilitation at Cincinnati Children's Hospital and is a current Board Director of the American Board of PM&R. Did I forget anything? Perfect. Okay. The only disclosure we really have is that I'm employed by the American Board of PM&R, and that's our only disclosure. So today, we are going to be going through kind of what we learned from doing a very large workforce study in PM&R. And because of some of our operations now, especially the longitudinal assessment, which probably most of you are participating in, we have a way of getting people to engage and answer questions about what are you actually doing, what are you seeing, what's your practice made up of, is it rural, is it urban, are you academic, are you private practice, all of these questions. Because as I hope we show you, it has importance to big decisions that are made for the field. And I think it's a service to the field that we were able to get the kind of response we got to do this workforce study. So with that, I will introduce Dr. Sabrawal and give him the opportunity to present his component of these talks. Wonderful. I'm good. People are coming. Well, thank you for finding this right next to the playroom and the kids' drop-off area. But, well, it's great, and it's great to be presenting with this wonderful group. So I am going to go to the next slide, if I can. Oh, I'm supposed to do this here? Point back there. Oh, point towards the back there. Point down. Oh. Did it work? Yes, it worked, because I was using the wrong one. I guess I'm supposed to point towards me. Normally you point the one that's pointing away from you for the next one. But anyway, we'll learn. Basically, we're going to summarize in this session, the three of us together, I think, all our talks. We're going to talk a little bit about the growth and focus of PM&R as a specialty, based on the data that Carolyn mentioned. Talking a little bit about the alignment between practice focus and subspecialty certification. And I'm going to wear my glasses. And also on the analyzing the impact, you know, what are the implications for the PM&R workforce. And then Dr. Pruitt, and to some extent Dr. Kinney, are going to talk more about the implications on PM&R training and residency and fellowship requirements. So a lot of this information from my portion of the talk is actually in the study that was published, I think, in July of this year in PM&R. So I would encourage you to look at this for additional details. This again is based on this data. Can you guys see the table from the back? I'm not sure how easy this is. Can you actually read the table? OK, that's good. So basically looking at, as Dr. Kinney mentioned, starting in 2019. So I think 2020 was the first administration of LAPM&R. But starting in 2019, people started registering for it. So that's when we started collecting, AVPM&R started collecting this practice profile and demographic data that people were given the opportunity to provide. And then every year when they're taking the LAPM&R, they have the opportunity to update that. So basically, these are the questions that are asked. And these are related to, it's easier for me to look at my notes than to look there in the slide. But they are looking at years in practice, work status, whether it's full time, part time, retired, or otherwise not working. The practice setting, looking at academic, private, VA, or hospital-based, or non-clinical. Of course, there are some things that are missing here. We haven't asked SNF, for example, or nursing homes separately. And I would say, if folks, and I know Dr. Kinney and Pruitt are going to talk a little bit about gaps in this and other things that we could be looking at, but if you amongst the audience have ideas or thoughts about things that we should be asking, please share those thoughts certainly at the end. Or if you've got a burning question or issue to raise, please feel free to interrupt at any point. But so, just to clarify, because it'll become easier when we're looking at the results. The years in practice, obviously, is a number. In terms of their practice status, whether it's full time or part time, people are just given the option to choose the one that is most relevant to them. For the next two parts, in terms of the practice setting and the practice area, people can choose multiple things, and they give a percent to those, and the percent just has to add up to 100%. So, if they're doing 50% inpatient, 40% outpatient, and 10% research, it just has to add up to 100%. The last thing that we ask is the area of practice focus. This one, at least at the present time, doesn't have a percent of this. People are just asked, what are the main areas of your practice focus? They can pick anywhere from one to all of those. Whatever they feel is amongst a significant part of their practice focus. Let me see if there's anything else in this. Does anyone have any questions on either this table or the process? No. Okay. In terms of the demographic characteristics, this data is out of 9,543 physicians. That is actually, and I'm actually, this is actually easier to see. I thought I might use the pointer, but, oh, I need the mic, I'll just take it, I'll just take it. Oh, rotate it this way, oh, good idea, good idea, thank you. The number is 9,543. I'm going to stress that again towards the end, but that's a large number. I think that this data is unique in the sense that it captures almost 97 to 98% of all practicing physiatrists in the US. Different from survey data and other things that workforce groups have looked at, where it's a very small proportion. That is a big strength of this study. Out of these, the majority of physicians are still male, PM&R diplomates, 62% or so. About 15% are over 60 years of age, and you can see the age here, about 43%, I think, are over the age of 50. The percent of female physicians, although there's still a minority, it's 38%, but that has increased in recent years. You can see on that second table that just came up, compared to about 31% of physicians who are 60 and over who are female, in the 29 to 39 year group, it's close to 43%. That's another big demographic shift. Any questions about this data before I go on to the next slide? Yes? How does it relate to the number of female physicians in male practices? You know, that is a good question that I don't know the answer to. Does anyone? Well, graduating from medical school is at least 50-50, if not even slightly more female now. So it's undersubscribed in PM&R still, even though it's growing, oddly, because it doesn't seem intuitive to me why that would be the case. But it is still the case that we are below what the graduation classes are in medical school in terms of male-female split. And again, there's a four-year lag, obviously, before residency. This data is only for practice data. So hopefully it'll catch up. Yes? Yes? With the over 60, is that maybe underrepresented also because of lifetimes or something? Yeah. Well, yes, probably. In terms of actively participating, as I said, you know, and I mentioned when I talk about the strength of the study, there was a AAMC paper that looked at AMA data files for practicing physiatrists and basically had, you know, it was in the high 9,000. So this is 98% of that. So of actively practicing physiatrists, it's still capturing most of that data. But there are folks, certainly only about 1.7% of people who are taking LAPMR are, you know, retired. They've been, they've put their status as retired. So it's probably underrepresented. Yeah. For those people who aren't in lifetime. Absolutely. And the other thing I would say is that this is a relatively younger group compared to physicians overall. Because I've read a study that says that overall for physicians 60 and older, or 50 and older, it's about 56% of all physicians in the U.S. So we're still a relatively young specialty, at least compared to that. Okay. Okay. You got this. Yeah. No, no. I'm changing the thing. Okay. The practice profile and practice settings. Okay. So here you can see, again, that years in practice and then working full-time, 87% are working full-time. And as I mentioned, the very few that are retired, 0.7% and currently not practicing could be for various reasons. Again, the total comes to about 2% or so. Okay. Okay. And then this is looking at their practice settings. And again, as I mentioned, people can choose multiple things. They just have to add up to 100%. So that first column that you see after practice setting is mean allocation. That means of all the physicians that are answering, for example, physiatrist practice overall 64.9% in an outpatient setting. So that's what it means. It doesn't mean that 64.9% are practicing in outpatient. It means that overall, for the group, folks chose the mean allocation as 64.9% for outpatient, 21.6% for inpatient, about 9% administrative that, you know, people can have different interpretations of administrative, whether it's billing and other things or whether it's actually administering a department, 3% in education. And we still do relatively little research, 1.6%, with 87% reporting no research. So the second column is number of percent of physicians who choose 100%. And the last column is percent of physicians who chose 0%. So for example, for outpatient, 64.9% is the mean allocation, but only about a third of physicians practice exclusively in the outpatient. That's the second column. For inpatient, it's 21.6%, but 56% of physicians have no inpatient work at all, which again is something we'll talk about in education. So there's a lot of data here. As I said, it's all in the paper in a little more detail. Does anyone have any questions on this table before I go on? Okay. Yes. Yes, sorry. Was there guidance on how they responded to that, if they do call? That is not, that was not asked, but that certainly is something that could be added in terms of, do you do weekends or evenings and those kind of things. Good point. Okay. And then coming to the areas of practice focus. So not surprising that musculoskeletal pain and sports medicine were the most prevalent areas of PMNR focus, followed by stroke. So as you can see, the practice focus areas that are asked for, and not everything is asked, and again, I think Dr. Kinney is going to touch about in some other areas that are not included. But from A to Z, if you go, it's amputation, brain injury, EMG, hospice, you can see this in the back, right? I don't need to read this. And then the second column is the frequency of choice and the percent who chose only one area of practice focus. So you can tell, 80% of folks reported more than one area of practice focus. Mostly it was one to three areas of practice focus, but 40% chose more than four, four or more areas of practice focus. Now, of course, folks' interpretation of what they thought was a significant practice focus may vary. And there is obviously some overlap between musculoskeletal and sports medicine, those kind of things. But that is how they chose these things. The things I would highlight from here, I think, are the, let's see, the, well, medically complex, about 0.4% chose that as their only area of practice focus, not surprising. But only 25% had, chose medically, care of medically complex folks. And you can see the others, again, as I said, musculoskeletal most common at 68%, followed by pain at 56%, with about 6.3% reporting exclusively pain. And then followed by sports medicine at 32%, stroke at 30%. And when you look at the combinations for practice focus, then of these, of all the 9,500 folks, 76,000 plus, 7,600 plus chose two or more practice focus areas. And not surprisingly, because of the overlap, pain medicine, sports medicine were the most common overlap in pain medicine and musculoskeletal. And then also stroke and spinal cord injury was the third, which is, you know, not surprising. Again, some folks do neuro rehab, and that might include spinal cord injury, as well as lower down on the list is brain injury as well. But the most common areas, the 10 most common combinations are listed here in decreasing frequency. And they're very congruent. Also, we did another study on subspecialty certification in PM&R that was published a couple of years ago, with very similar, you know, different percentages, but very similar sort of the order in terms of pain being the most common, and then pain and sports medicine being the most common overlap in areas where a subspecialty certification is offered. Then coming to the subspecialty certifications themselves. So this table lists the subspecialty, the number who currently have subspecialty certification as of the time this paper was, which was some time in the last year or so. And then the last column is divided into two, into those with a fellowship and practice track. So some newer subspecialties, such as brain injury medicine, where the practice track eligibility, I think, ended only end of 2022. So only the last not even two years. Not surprisingly, the large majority of practice track, it's 88%, with about 12% being fellowship. And the numbers are relatively high, too, for brain injury medicine. And that is consistent with data we've shown in that other paper that I quoted on the subspecialty certification in PMNR, is that as when practice track eligibility ends, the numbers go down. Because it's only folks who are doing fellowships that can apply for that. And so that is why, for spinal cord injury medicine, for example, 62% are fellowship trained at this point. The folks who are responding their practice focus, just because over time, folks with practice focus who did not recertify have dropped off. And so it's a smaller number. Similarly, for peds rehab, it's about 52% that have done a fellowship. Any questions on this table? OK, this table is a little complicated. And I've sort of highlighted some of the main areas I wanted to bring up. Again, just to check, because this one has a lot of data. You can still see it from the back there? OK, good. So this is looking at the alignment between the subspecialty certification and the practice focus. The practice focus is on the y-axis. The certifications, obviously, the six areas of certification that PMNR currently has, the hospice and palliative care, no longer is a PMNR-sponsored fellowship subspecialty. But the currently certified, the certifications are listed on the x-axis. So I've highlighted a few. So if you look, for example, at brain injury medicine, the first column, so you can see the ones that are in bold are the ones that are most common for that area, and the one where the subspecialty certification is. So as you can see, for all the subspecialty, the majority of practice focus, the highest frequency of practice focus, which ranges from 81% for neuromuscular medicine to 96% for pediatric rehab medicine. But in the 80s to 90s percent range, at least the folks who are subspecialty certified report that as one of their areas of practice focus. Again, this is not a percentage of the time that they spent in this. This is the percent of folks with certification who check that as their current area of practice focus. So that's one thing. And then you can see, for example, if you look at spinal cord injury medicine, for example, 90% check that as their area of practice focus. But then 42.4% also do brain injury and a whole host of other things. If you look at brain injury medicine, 88% do brain injury. 43% actually do medically complex, and about 31% if you look at medically complex, it's primarily folks with brain injury medicine and spinal cord injury medicine who picked that with greatest frequency. Not surprising, because those are inpatient sort of based subspecialties where you do have a lot of medically complex patients that you're taking care of. And then stroke also, again, overlaps with brain injury medicine and SCI medicine. And then the last thing I would say in this one is a lot of overlap. In addition to the spinal cord injury and stroke and BIM, of course, pain medicine, sports medicine, and musculoskeletal, a lot of overlap. So if you look at sports medicine or pain medicine, for example, 91.8% report check pain, but 71% also check musculoskeletal and 33% sports medicine. The other thing to add here, and maybe Dave will speak a little bit more about it, if you look at EMG, in addition to neuromuscular medicine, pain in sports medicine and doctors also, more than others, still list EMG as an area of practice focus. So the bottom line is that the area of subspecialty certification is not the sole practice focus area for most diplomates in the subspecialties. Peds rehab medicine is most likely to select pediatrics as their sole practice area. But again, it's only 43.3%, even if those with certified in peds rehab. And as you can see, SCI after that at 29.8%. Not surprisingly, brain injury medicine is only 7.8%. I think that reflects the practice track eligibility, because folks are taking the brain injury exam because they're currently eligible. That's what was historically happened with the other subspecialties as well. But they have brain injury only as one of their areas of practice focus, not the sole area. So the strengths, again, I would reiterate that this really is unique in that it captures close to 98% of physiatrists actively working in the US. And the ABMS also does an annual report that includes all physiatrists who are board certified. They don't really separate them out into actively certifying. And so this represent about 80% of that number as well. Now, of course, those numbers are probably actually even more than that, because the ones included in the ABMS report may include folks who are retired or those who may no longer be alive, but are still on the boards, because there is no official notification of them passing away. But that's still a very high number. So there was, for example, a workforce that was commissioned by the AAP that published a couple of papers in 2021, where they sent out surveys to about 2,000 physiatrists. The response rate was as typical as for these surveys was about 30%, 32%. So they had about 600 or so. So A, those numbers are really small compared to this. And B, then there's probably more sort of response bias and other kind of things that come in versus this particular paper. The limitations are that it's self-reported information. And so it's not been verified other than that. And folks' interpretation of these questions, what they consider as significant enough to call a practice focus, for example, may vary. And this study took the most, for folks who had updated their data annually, this study took the most recent data to count for those folks. But some folks may or may not always update their data every year. So there are those kind of limitations. And as I mentioned, there are some things that are missing. And some of you have already pointed out kind of things that we are not asking. And of course, we are not asking any reasons for why people are doing this. There was a study, for example, I think Yang and others, that published in about three or four years ago that looked at why people choose fellowships. And the most common areas for PM&R were either the work schedule, work-life balance kind of things, or the exposure they got during residency were the two most common areas people cited as to why they chose a particular area of fellowship. But this study did not look at those. And then, of course, as you mentioned, those with non-time-limited PM&R certificates, we don't have those numbers. Again, those numbers are dwindling. There were maybe 200, 300, 400. And I am going to maybe stop. Well, let me do the implications. I think we've covered most of these. A, it's a relatively young field, but still folks 50% and over, 43%. So as we look at workforce kind of things, we should consider that. Increasing percent of women in the cohort, which is great. Now, of course, those parental roles and other kind of family things are hopefully evolving towards greater equity. But we're still not there. And there's still relatively recent data showing that of physicians who are 55 years or younger, women generally work four or five hours less per week than their male counterparts. So that may also influence the workforce supplies kind of things. And then in terms of the overall rehab needs, we've already talked about the medically complex. If 56% of physiatrists are not doing any inpatient work, who's going to take care of those medically complex folks is another area. And then, of course, we don't really ask about the geriatric population. But the population in the US is aging. We know that, actually, I read something from the census that between 2017 to 2030, they were projecting a 9% increase in the US population and a 44% increase in the population 65 years and older. So actually, tomorrow, we're doing a talk on age-friendly health systems at 915. So come to that, because I think that is going to be an important area going forward. And then, of course, in terms of subspecialties, one thing to look at the numbers. But I think that gets complicated and nuanced by these diverse areas of practice focus. And not all subspecialty care is being provided by subspecialists, since others are doing this as well. And with that, I'm going to give it over to Dr. Pruitt. Thank you. Great. Would you mind turning this? Oh, sorry. Thanks. Do you want it closer? No, that's OK. Your eyes are better than mine. Oh, maybe. So can you guys hear me OK? OK. Great. I'm Dave Pruitt, and I'm going to talk a little bit about how we use this information to help guide us in terms of the next steps to take, in terms of the revisions to the program requirements for PM&R residency programs. So as the ACGME begins its efforts for the PM&R residency training revision process, which have undergone, haven't undergone a revision for over 10 years now, the pandemic plays into that a little bit. This data can also provide some input into decisions about the need to make changes to our overall training program requirements to meet the needs of both the field, but also to meet the needs of and consider opportunities to adopt some new educational philosophies of care as well. There we go. So the details of the overall process that we put together for the tri-organizational GME committee is detailed in the PM&R journal and in the American Journal of PM&R. So I'll let you take a look at that at your leisure and not go into great detail about the entire process. But I'm just going to hit on some basic points with you to give you an idea of what went on over this eight-year process to kind of get a sense of what was going on. To kind of look into what we could revise in terms of program requirements for PM&R. So the tri-organizational GME initiative was a deliberate attempt by the three major organizations of PM&R. So the American Board of PM&R, the American Academy of PM&R, and the Association of Academic Physiatrists, who worked together, recognizing that collaboration between the three of them and using the same resources or shared resources to really be the best in terms of achieving the broadest input into identifying potential changes to the residency requirements as they exist right now and to best prepare physiatrists for future practice. So these organizations decided to pursue this opportunity, like I said, eight years ago, and they decided to do so proactively. So the ACGME didn't ask the PM&R organizations to do this, but these three organizations decided to do this proactively without a quote-unquote duty to do so. And so I think it's really nice that these organizations took an opportunity to really get their heads together and the resources from all of their organizations to say, how can we provide some input to really improve the educational process that we're providing for our future PM&R practitioners? Oh, I'm hitting the wrong button. There we go. As the leadership of these three organizations convened, the primary goal of this collaborative was to identify opportunities to enhance GME training to PM&R residents and to align these with the genesis of new approaches to program requirement revision, specifically looking forward 15 years down the road, which is what the ACGME is kind of thinking for all of their program revisions at this time period is to kind of look proactively 15 years down the road. So we're looking at, in our case, 2039 or 2040, and what will practice look like at that point? And what do we need to forecast to plan for that so that we're training our residents now to be able to practice in 2039 and 2040 at their best capacity? Another major focus of this collaboration was to improve the alignment between what is being taught and the experiences that residents have in our academic centers and the clinical needs of our broad patient base now and in the future. So I'd like to share with you some of the core concepts that were illuminated through our discussions with a large number of individuals and focus groups that were conducted over the eight years of this initiative. First is that PM&R is a field, like many others, that has demonstrated significant evolution since the initial formation of our field in the 1940s. Healthcare and PM&R's role in healthcare have needed to adjust to the many changes during this timeframe, and we've had to adjust our training periodically as a result of this as well. There are currently around 110 programs that are accredited through the ACGME, and even though we have these curriculum requirements, there's still a fair amount of variability from program to program, whether that be the population that's served, the type of CNS programming or musculoskeletal programming that each program has, and those strengths, that's really a strength that we have, that we have some variability within our program, and some of our residents, our medical students really look at that when they're deciding about which programs to pursue for their residency program, and what kind of fits, what they project might be their interest down the road after they finish their residency while they're in their fourth year of medical school. The focus groups also pointed out that there's also some acceptable variability in the learning and the mastery trajectories that residents have during their training, and perhaps we as a field need to be more attentive to these competency assessments of individual residents during their training, so that we can develop some potential competency assessments to conduct on these residents, to help to adjust the residency training program to help meet their needs in terms of becoming the best physiatrist that they can be. As a result, there's some good discussion about the need to consider the implementation of competency-based medical education strategies to the PM&R program requirements, and this is much in alignment with what other fields are doing as they do their revisions to their residency requirements as well, so internal medicine, pediatrics, anesthesiology, have all kind of implemented some of these competency-based medical education strategies as they've looked towards revising their program requirements as well. Lastly, as some of an outsider to this process, when I initially joined this program, I was a recent graduate of the RRC, and the group decided we'd really like somebody who has some ACGM experience to come and be a part of this to help guide us in terms of thinking about program requirement revisions. I was really impressed by being amongst these three organizations and really the coherence of the process and the lack of one group saying we're gonna be the owners of this and the rest are gonna follow, but it was really a cohesive process that these three organizations worked together to say how do we move forward with providing input and providing focus groups to get us to a better place in terms of recommendations that we can make to the ACGME to think about in terms of the revision process. So this slide is a slide of the steering committee members that helped to lead the overall process for the GME committee that we had that provided these recommendations. In addition to this committee, we had hundreds of individuals that provided information to us through focus groups, and these were individuals who came to us from a broad array of different experiences. Some were clinical experts, some were researchers, some were administrators. It also involved program directors, fellowship directors, and department chairs. So we really got some broad input from a lot of different individuals that gave us some really good input as we started to think about what areas we really needed to provide some suggestions and recommendations to the RRC and to the Program Revisions Committee as they moved forward. So the multiple focus groups that the consulting group utilized at the beginning of our project had several recommendations for us and a few of the critical ones are highlighted here for you and I'm going to talk about a few of these for you. So the most resounding theme from the focus groups for me was that all residents should be trained as PM&R generalists in the core or the foundational areas of PM&R practice without an option for early subspecialization at the beginning of their training. PM&R residency training as it exists right now is deliberately very broad in its current state and it provides experiences in all of the... most areas I should say of PM&R practice. This is necessary given the broad and multi-focus practice that the majority of our diplomats reported in the practice study that Sunil shared with you before my talk today. The focus groups also emphasize the need for residency training to ensure the inclusion of multiple settings in which physiatrists practice, so inpatient and outpatient, but also include the addition of areas like skilled nursing facilities which are a growing practice setting for physiatrists. The focus group participants felt that many PM&R core principles occur in many different practice settings as well and should be employed in these different settings including musculoskeletal medicine which occurs both in the inpatient setting and in the outpatient setting. The focus group participants also endorsed the skills and competencies that are addressed in the PM&R ACGME milestones for PM&R residencies as well as in the AVPM&R initial certification examination outline as being very broad and thorough without the need for us to create additional lists of expected skills that need to be attained during residency training or during fellowship training. There was overall consensus that the recommendations for training recommendations should include general themes and not be too prescriptive and allow for some flexibility, preserving the inherent and the advantageous variety of strengths that I talked about in my first slide in terms of having some variability amongst what we offer in the different residency programs that we have. And lastly there was a lot of positive feedback from the focus group participants that this initiative was set into place by these three organizations and was being collaborated on instead of being completed separately without input from the different areas. So next I'm going to share with you some of the key concepts that the steering committee had and I'm not going to go into great detail. Like I said you can read that detail in the PM&R journal or the American Journal of PM&R to get a little bit more detail, but I want to hit on a few of the specific areas. It's really important for me to share with you that these areas I'm going to share with you are recommendations that the GME committee shared with the RRC and the program revisions committee. So these have to go through the process through the program revisions committee to identify whether they are in agreement that these need to be pursued and whether they're going to pursue these and then we'll have the opportunity if they feel that way to see a draft of those and make comments to those before they go into action. But again these are just recommendations that we as a group are sharing with the RRC and the program revisions committee of things to be thinking about. And the PM&R revisions committee is currently working, I think they started December or January of last year, on the process but they're currently still in the process of writing and finalizing program requirements. So I'm not sure if we have a date yet of when that's going to happen. So as a steering committee subgroup we attempted to be strategic in our thinking about the process of how are we going to collate, pursue and enact the input that the tri-organizational committee received from our focus groups in terms of improvement. It's important to assure you that the recommendations could align with the... It was important to assure that the recommendations we were making aligned well with the current structure that the ACGME program requirements already have in place so that they would align well so that the ACGME committee didn't have to kind of think about where these recommendations might fit in in the current requirements. The areas that we ended up making recommendations toward include the following ACGME subgroups. The length of the educational program, the ACGME competencies, specifically patient care and procedural skills and the curriculum organization and resident experiences. So first I'm going to start off with length of educational program. So overall our focus groups were pretty consistent in terms of the recommendation that... and the experts in our field that the overall duration of training for PM&R residency should not change and that the initial year of training in medicine, internal medicine, in pediatrics, preliminary year or transitional year is really an important part of the overall training process that we do for residents. Where we did recommend a change in this section is under what's called specialty-specific background intent. The specialty-specific background intent is a section that allows for clarification about a requirement for more definition of what the requirements are trying to accomplish. The recommendation here is that part of this core requirement is that the specification that the internal medicine revisions put into place was also incorporated within their revisions to help emphasize the intended use of competency achievement to allow for increased flexibility in an individual resident's educational experience trajectory. Specifically the recommendation for us was that these requirements were written to be flexible and allow program directors the opportunity to create more individualized educational experiences for residents who have achieved or are on a trajectory to achieve competence in the foundational areas of physical medicine and rehab. And we'll talk about this in a few slides in a little bit more detail. This was really a guiding principle for internal medicine when they did their revisions in 2022 and really echoes a lot of the feedback that we received from our focus groups as well. Next, there was a consensus from the multiple focus groups that the current requirement language for the ACGME electrodiagnostic requirements should be considered for revision or modification as well. The issues identified included that EMGs should be considered similarly to other procedures that are included in the PM&R ACGME requirements in terms of having a case log expectation for electrodiagnostics, but not both a case log expectation and a program requirement delineating the exact same requirement. Secondly, with the current and anticipated change in the field of PM&R, the emphasis and the implications on the number of EMGs, known as the 200 slash 150 rule, should be reevaluated and modified or adjusted. Program requirement language for electrodiagnostics has, interestingly, not been changed and it's relatively unchanged since the 1990s. There was some modification to the requirements 10 years ago at the time of the implementation of the case log system, but 1990 to 2024 is a long time to go without kind of thinking about that requirement and what those numbers entail. The tri-org committee review noted that programs typically allot anywhere between four and six months that are dedicated to achieve the 200 slash 150 rule for each graduating resident, and this was based on results of an informal survey that was conducted of PM&R program directors. One of the reasons for that time allotment of four to six months, just so you have an understanding of this, is that time spent during residency doing EMGs must be time outside of the time requirements for inpatient rehab and outside of the time requirements for outpatient rehab, which are both 12 months in duration. So through this, residents are required 12 months of inpatient, 12 months of outpatient, and then sometimes four to six months of EMG and then having only an additional six to eight months to fit everything else that's important in PM&R into their training program. It was also identified through our process that approximately 50 PM&R candidates undergo certification through the American Board of Electrodiagnostic Medicine or the AANEM annually, which accounts for approximately 10 to 11 percent of all residents each year. With oversight, the tri-org committee... From the tri-org committee, multiple formal and informal conversations took place to kind of dive in deeply to these EMG requirements and get a little bit more information before we settled in on kind of what our recommendation was going to be. First of all, Dr. Wersowitz met with program directors at the AAP Residency and Fellowship Program Directors Meeting in May of 22 and included a thorough review of the program requirement and case logs and initiated some feedback there from program directors as part of that meeting. And then we had many tri-organizational meetings following this to have some more discussion about EMGs and included representation from the AANEM as part of this to express viewpoints from them as well. And subsequent to that, we had some EMG experts that were put together as an EMG focus task group that met over a couple of months in the summer of 2022 to dive in what we thought was even deeper into the issue to come up with maybe some additional thoughts on what could be done with the 250-150 EMG requirement. Ultimately, I'm sad to share with you that consensus was not achieved from all of this process regarding a change in the 200-150 numbers through these groups. So in essence, the tri-org group did not make a recommendation to reduce EMG experience or reduce the number of EMG numbers that are required during residency. The committee, though, did recommend a clarification from the ACGME PM&R revision committee to provide consistency in their revisions when they do their revisions of all procedures that are required for a physiatry resident to gain skill in during their residency training program. So our verbiage to the committee was to continue the procedural expectation of EMG amongst all other ACGME minimum standards of the 2015 memorandum, which is a memorandum that was put out of all of the case log requirements that exist in PM&R. We did recommend, like I said, removal of the 200-150 EMG requirement, but did so just to say, let's eliminate the duplicity of having numbers in both the case log requirements and a separate requirement in the requirements of ACGME. We also recommended that the program requirements revision committee for PM&R should determine what those minimum EMG requirement numbers as all other procedures should be, whether those change or not from the previous memorandum, with stipulations regarding procedural experiences incumbency as per the minimum standards memorandum of 2015 or an updated version if that occurs. We also felt it was important to say that programs under the guidance of the program directors for individual residents should have the opportunity to opt for additional EMG procedural experiences if they need to achieve minimums required for AA and EM examination eligibility when that's desired by a particular resident or an individual who decides to pursue this. In the current practice focus survey, diplomats were able to select the percentage allocations for all of the practice areas, and this is a slide that really shows just all of the different practice areas, and I wanted just to highlight the third one from the top, EMG. So electromyography was selected by 28.8% of all diplomats in PM&R, and 68 of diplomats identified EMG as their sole practice area within PM&R. This finding really is in alignment with the evidence that we found in the majority of diplomats that demonstrated multiple areas of practice focus, so really it's not surprising that a very small number of our diplomats practice only electrodiagnostics. When we further looked into this information in regards to EMG practice focus, we noticed that a smaller percentage of younger physicians, only 23% who are between the ages of 29 and 39, indicate that EMG was one of their focuses of practice compared to older physicians, so those who are 50 to 59 and probably not in that category of physicians who are aged out of doing continuing certification, 33.9% of those are doing EMG as part of their practice. This is a little bit of a concerning trend that even despite no changes in program requirements in terms of the numbers of EMGs that you're practicing during residency, that even with that staying consistent over 30 plus years, we are seeing a decrease in the number of physiatrists who have EMG as a part of their practice. And this is a table that Sunil provided in his portion of the talk earlier. The association between current subspecialty certification and practice focuses is demonstrated in this table and the area of subspecialty certification, as Sunil pointed out, is not the sole area of practice for the majority of diplomats who have subspecialty PM&R experience. A practice focus within this table is EMG and it exists in some capacity among all of the certifications that we have, subspecialty certifications that we have in PM&R, with the most, 88.3%, amongst those who are certified in neuromuscular medicine. But a quarter of those who are certified in pain medicine and a quarter of those who are certified in sports medicine, two of our larger subspecialty certification groups, reported a focus of practice in electrodiagnostic medicine. So going back to the additional areas of recommendations that we made from a PM&R standpoint is the area of curriculum organization and resident experiences section within the ACGMA requirements. Our colleagues in internal medicine, as I shared before, created a very specific specialty specific background and intent that our steering committee reviewed and we felt would be beneficial for our revision committee also to consider. So we included it as a recommendation to them to review. The evidence from this practice survey also strengthens the need to consider the specialty specific background and intent. So some of the key points to the specialty specific background and intent... I wish I had an acronym so I didn't have to say that every time, like S-A-S-B-I... are that program directors and leaders are assessing individual residents' future plans and their interests and intermittently assessing their competence in the foundational areas of PM&R so that consideration can be made and opportunities to broaden that individual resident's educational trajectory throughout the individualized educational process. These individualized educational experiences are determined by the program director and take into account multiple things. Number one, a demonstrated competence in the foundational areas of PM&R, like I've said. Number two is an available resources within the program. Number three, the program aims. And number four is the resident's future practice plans. Secondly, programs have the opportunity to allot more than potentially six months of individualized educational opportunities for residents who have achieved or are on target to achieve the competence in the foundational areas of PM&R. This also allows for potential increase in educational time in an area that the resident has an interest in pursuing, but again, they have to demonstrate a competence in the foundational areas of PM&R before we allow that to occur. Lastly, there was a recommendation made to encourage residency programs to collaborate together as well as with our academic societies to attain educational programming for trainees and their programs on topics that might be harder to come by or challenging for all programs to have the capacity to provide expertise in. As we've shared in our practice data, the broadness of focus areas that many physiatrists practice in is an argument that physiatrists in training should have a learning environment that is similarly broad. Some residency programs are going to have the capacity to train in all of these broad areas, but most programs are going to need some help in having expertise in each and every area of PM&R practice. And so we really felt it was necessary to put a requirement in place to say it should be expected that programs have the capacity to reach out to other programs and to their subspecialty organizations to provide educational opportunities for interest training during residency. In addition, input was provided during our focus groups and committees to make updated recommendations on both core and evolving topics of PM&R that should be included in the program requirements for didactic training of program physiatrists. So different areas that were suggested were topics such as physical modalities, genomics, population health, access, and a number of other specific areas that we've shared with the revision committee to consider in their process. And lastly, I just provided a composite of the recommendations that were provided from the tri-org group to the ACGME revisions committee. And again, details for all of these areas are provided in the PM&R Journal and the American Journal of PM&R if anyone is interested in pursuing these a little bit further. And with that, I'm going to pass the baton to Dr. Kinney. Okay, so can we pull up the slides that we loaded earlier? I'm just going to talk a little bit about how this workforce study was put to some other uses. You heard sort of an overview of the workforce study from Dr. Sabrawal. You heard how some of the information was also applied to give recommendations to the ACG and the ERC as they go through their process of rewriting the requirements for residency training. But there's other things that come up that the workforce data are useful for us or should be useful. And I think that's going to evolve over time. One of the questions that has been put to us through the Academy and through other very interested groups has to do with the possibility of creating a subspecialty in cancer rehabilitation. There's a very core group of interested people who want to do this. So we thought a place to start was to ask, in the annual registration for longitudinal assessment, this workforce study, is cancer rehabilitation something that you do? And that first question, people could pick as many things as they wanted. We really didn't limit it. People could pick all the different practice focus areas that they felt made up what their practice was. So as Dr. Sabrawal mentioned, we had over 8,000 responses, actually closer to 9,000 responses on this. Of those, about 10%, 10% of the respondents indicated that they included cancer rehabilitation in what they do. And that amounted to about 836 people. We showed you earlier that we asked people, well, pick how many apply. Pick how many practice focus areas apply to what you do. And I think Sunil mentioned, wherever he went, that most people picked like three. Three was about average. And there were some groups that really were very focused, you know, pediatric rehab. Those people, that's what they're doing. And pretty much that was their focus, and probably the only focus. For other groups like pain medicine and sports medicine, they too had pretty small numbers of things that they picked. People doing pain are doing pain. Some of them are including EMG. People doing sports are doing sports. And really, they didn't have a big spread of other things. Even though, as Sunil mentioned, there were people who put more than four possibilities of things. But most people were in the threes range. Interestingly, though, the people who picked cancer picked like almost eight things that they were doing. So kind of an outlier. Most people are not doing cancer rehabilitation as the focus of their practice. They're doing it, that 10% of respondents who included it as something they do. But they're doing it with a lot of other stuff. They're doing it as part of a general practice. They may be seeing cancer patients on an inpatient service, outpatient. You know, it's just part of general PMNR practice for most people. Certainly there are physiatrists who are working in, you know, cancer institutions and so on who are very focused on cancer rehabilitation. But not too many. Most people are including cancer rehabilitation, if they are including it, as part of an array of different things they do within their practice. So we went back after that first survey, which came, you know, was data that came from the registration last year for the longitudinal assessment. And we asked some questions about cancer rehabilitation directed at the people who said they did it. So that 856 or whatever it was, people got surveys from us. But only about 180 of those got responses. We didn't have the same capture that we had for the longitudinal assessment. This was really responding to a survey. So, you know, I think some of the people who are really gung-ho responded to this. But these are the questions. So if we had a subspecialty, would you do it? That was the first question. Second question, it was, I'd help. I'd volunteer my expertise to write the questions and stuff like that. Third question, I would pay to be a participant in cancer rehabilitation, because these processes creating these tests, this is expensive. It's actually really expensive. And so, you know, we have fees for all the tests that we generate. Obviously, this would have to have a fee. And, you know, would you be willing to pay a fee? And we kind of wanted people to understand that if we offer a subspecialty, it possibly would be something that other fields could participate in. You know, it wouldn't necessarily be exclusively PM&R. There might be people in internal medicine who are oncologists who decide to do this. It doesn't mean that we would have to do that, but in the world of the American Board of Medical Specialties, of which our board is one, part of that process is to ask the people who might be interested whether they want to be a co-sponsor of, you know, such a subspecialty or, you know, a board that qualifies people to be eligible to take the test. For example, you know, we let, we're a co-sponsor of sports medicine. We don't administer that test. The American Board of Family Medicine does, but we're a co-sponsor of it. And so that process would be applied to this as well, and would that dissuade people who have it in their minds that this would lock down cancer rehab as a PM&R thing? You know, maybe it would, but maybe it wouldn't. And then we asked, finally, did the people who are responding complete, you know, the fellowships in cancer rehab are not, at this time, ACGME-accredited. So did you complete a fellowship, a non-ACGME-accredited fellowship? And these are the responses we got. So people who answered this 179, which I think actually were people who were pretty committed to cancer rehab. I'm guessing there was a blog out there telling people, respond to the survey. But there was interest, you know, and people said they would, you know, about 50% or 60% of these people said that they would be interested in pursuing the subspecialty. And about the same number said they would help, which is nice. A fewer number said they would pay. And that's not surprising. It actually made me smile a little bit. But, you know, paying for this is, it's a stress point for people. And I'm not surprised that even though they're enthusiastic, it really does give you pause if you think you have to pay for another process. Most people, though not all, were not dissuaded by the fact that others could come into the field. Most people said no, that was okay. But about 30% of them said, hmm, that's probably not good, you know. So that's the response on that. We did have a lot of other comments that were written in as well, and I'll go through these. As you can see, most of the people responding here did a non-ACGME accredited fellowship, which to me says these aren't the core people who want to see this turn into a subspecialty. It's not the majority of that 800 and some people for whom cancer is one of eight different things that they're doing in their practice. If they did a fellowship in cancer rehab, they're more interested, much more likely to be interested in pursuing a subspecialty. The comments were kind of all over the place, given that I think most of that 179 who responded were people who kind of want to see this turn into a subspecialty. Interest and support, you know, people feel like it's an area that needs specialized training, improved cancer care for patients. Equally, there were a lot of comments about whether this should be a subspecialty and citing barriers for patients, financial burden on providers, and that some people felt like the existing training in PM&R should suffice. The fellowship training also had mixed opinions. There was, and there always is, advocacy for grandfathering people in without a fellowship training, but others felt like the variability even in the existing fellowships should mean that we go the route of an ACGME accredited fellowship. There was some concern about subspecialization actually ending up limiting access to care and diminishing the role of people who are in general PM&R practice. People were concerned about the financial considerations, additional cost, and so on. Some of the people who responded felt like, yeah, they do cancer rehabilitation, but not enough to want to do another subspecialty. So I would say if you grouped these as positive, neutral, negative, it was kind of evenly split. Positive about 15%, overall positive, and about 16, kind of neutral, and about 24 were negative in terms of, you know, for the reasons I gave, pursuing a subspecialty. Now I'm just, I bring this up not because I have the answer to this or a decision from the board about this because we do not. I bring it up because this talk is about the workforce and knowing what the workforce is doing and using that information to help inform strategic decisions that the board and the academy and the AP will make and the ACGME will make. So the fact that we now have a tool, which is the annual registration for the longitudinal assessment means we can ask different questions periodically and try to help with these strategic decisions that will, you know, give us some direction, data-based direction on judgments we have to make about these things. How is the board likely to use the workforce data in the future? There's just, you know, some things that came to mind. It's obviously important on our exam blueprints to know what people are doing. What's the point of a blueprint not actually being a reflection of important things in practice? It makes no sense. So asking will help us keep all of that up to date. I just talked about subspecialty development and knowing if there's interest, knowing how much interest and how targeted something is should help with that workforce. You heard a whole section here already on the ACGME and the training requirements. Should we promote fellowships? Fellowships in what? Should they be ACGME or non-ACGME fellowships? A lot of people are doing non-ACGME fellowships in all kinds of things now. But the workforce data kind of gives us an idea of what might be useful in that regard. It helps us mitigate bias in assessments because it shows what people are actually doing. The assessments are not a reflection of anybody's pet peeve and that kind of thing. And it helps our board know about whether we want to be a co-sponsor or a qualifying board for subspecialization that gets maybe created by other boards. Do we want to be part of it? That kind of thing. So we're always kind of paying attention to that so that people in PM&R have opportunity if they want to become part of a subspecialty process that's being administered by another board. And that's it for me. And time for questions. Yes? There's been quite a, there have been a few publications about cancer rehab and to what extent it's part of the curriculum. You want to say anything about this? Yeah. I don't know. I work in pediatrics and our pediatric oncology residents or fellows don't have any requirements in place to say that they have to spend time with a PM&R physician, but programs will, I think, allow for that to happen if fellows have an interest in doing that. But unfortunately, unfortunately, unfortunately, it's not something that's required. Right. It's not, it isn't. I think it happens in a sense naturally because it's hard to avoid, you know, in, it's hard to avoid taking care of patients with cancer. They show up with non-traumatic spinal cord injuries and brain tumors and, you know, all kinds of things related to both the cancer and the treatment. So I think it's, I think it's difficult to get through residency and not have exposure to it. But as far as a curriculum, no. usually requires the physiatrist to self-advocate to become part of the team and then something clicks that they start to realize you know and then they're part of the team so Inquired by whom? On the data that we collected. Oh, we haven't changed it. Yeah, no, I think that we'll, we haven't made a decision yet. I think we'll leave it on there because there's so much interest right now and we'll just see how it changes over time, which seems to me to be a metric that's important here. This is the very first snapshot we have of the majority of our workforce and the first kind of data we have about this. So, you know, just off the top of my head, I think that we would need to follow that trend for a bit. That's the majority, yeah. Do you think that's happened in, like, spinal cord injury? I think it happens to pediatrics all the time. Well, yeah, I think so. I actually think it has happened in spinal cord injury. I've seen it in patients, but a lot of them are just like, ooh, I'm not a pediatric specialist. Yeah, that's a good point. The counter to that, though, would be that table that showed most, you know, spinal cord injuries not just being practiced by spinal cord injury physicians, but, you know, some folks who are not certified in spinal cord injury are also doing, at least check that as their practice focus, what percent we don't know. This is the—this is the yin and the yang, and I— We don't have enough to do that right now, so that's a problem. Outcomes, yeah. The, one of the things that we don't ask about, but is I know a factor in this, is that if we went to ACGME accredited fellowships for this, of course it would help with the variability and things like that, but would also change potentially the incentive for an institution to have a fellowship, financially, you know. And so, I don't know, you know. It's interesting, because I think when some of our other subspecialties were developed, it was really a turf issue. You know, when I think about spinal cord injury, there was this sense of urgency to make sure PM&R owned that. That was our thing, you know. Traumatic brain injury, that was our thing. Pediatric rehab, these were our things. This is not a turf issue. This is different. It's different, the reasons for doing it or not doing it. It's a different time, in a sense, but it needs to be a different process because of that. You had a question? You know, there are people in practice now for whom there were really no fellowships at all. Everybody was a generalist when they finished training. And then, you know, there started to be a few spinal cord injury, a few brain injury fellowships. But it's definitely now, people finish residency, almost all of them do a fellowship, whether it's accredited or not. Yeah, you know, yeah. We had about 800 people, and it was about eight last year. Yeah. And brain injury is the same. He's the same. This year was really bad for us. much less likely to be doing everything. You actually did raise the alarm about this data with regard to one of the core areas of PMNR, which is the inpatient rehab care of people. And we, if people don't go into that, we'll lose it. And that will become internal medicine or family medicine or something, and that'll be gone. What has been sort of foundational for people in PMNR jobs-wise and career-wise, that's going to be gone. And I think this study raises the alarm, actually highlights that, because so many people are choosing pain and sports medicine as what they want to do. It's the reimbursements. I mean, when I joined, and of course I'm dating myself, but 89-90, it was DRG exempt. All the graduates from residency were going into multiple offers for inpatient rehab. Absolutely. Well, there still are multiple offers, it's just that there are people in PMNR on taking them. Other questions? Yes? Is there a forum to add additional questions to a poll in the late PMNR? Yeah, well, we could. It might be late to do it for this year, but we're always open to additional questions. I'm curious. What's the question? I didn't hear it. So I had a session earlier today about hand and upper extremities. Oh. OK. Yeah. Yeah. Well, a lot of these people specialize in spasticity, and that's all they do. That's all they do. Every once in a while, we also get asked to do like a subspecialty in limb deficiency. And again, it's like, yes, it is a very specialized area. Feels very core, PMNR, to me, but this probably because it was core when I did my training, I don't know. There certainly is a specialized body of knowledge and things like that. We used to do all of it. Medically complex. Well, the skilled nursing was one that Dave brought up and should potentially be part of one of the questions. You know? Yeah. Because there's so many, I talk to so many private practitioners. It's a way that they make extra money sometimes. Right. 13% said other, and we don't know what other. They're practice focused. Yeah. So there's obviously gaps. Well, thank you. Thank you. It was an interesting conversation.

American Board of Physical Medicine and Rehabilitation

workforce study

longitudinal assessment participation

practice settings

outpatient care

musculoskeletal medicine

sports medicine

subspecialty certifications

PM&R residency training

competence-based education

cancer rehabilitation

electrodiagnostic medicine