Environmental scanning originated in the business sector decades ago and has been adopted by academic medicine and other healthcare entities.1,2 Environmental scans determine occurrences and trends in an organization’s or field’s internal and external environment of great importance to future success.3–6 The results can be useful for shaping goals, informing strategic decision making, and directing future organizational actions.3,6,7 Environmental scanning can use a variety of approaches,5,8 with information gathered from both person-focused (e.g., experts) and non-person-focused (e.g., literature) sources.6,9,10
Beginning in October 2020, the Association of Academic Physiatrists (AAP) convened a strategic planning group, composed of physiatrists representing a diversity of professional roles, career stages, race and ethnicity, gender, disability status, and geographic areas of practice (including contributors from across the United Stated, Canada, and Singapore). This strategic planning group performed an environmental scan to assess the forces, trends, challenges, and opportunities affecting both the AAP and the entire field of academic physiatry (also known as physical medicine and rehabilitation [PM&R], physical and rehabilitation medicine, and rehabilitation medicine). This article presents aspects of the environmental scan thought to be most pertinent to the field of academic physiatry organized through the following five themes: (1) Macro/Societal Trends, (2) Technological Advancements, (3) Diversity and Global Outreach, (4) Economy, and (5) Education/Learning Environment.
In a continuously changing healthcare industry, flexibility and adaptability are critical qualities for success. The field of academic physiatry has historically maintained a nimble approach (e.g., open collaborations and adoption of efficient innovations), which has enabled successful adaptations to a rapidly changing world. The field has the opportunity to successfully adapt to new challenges, including demographic trends, climate change, geopolitical conflicts, population health needs, and major public policy shifts. Strategies to meet these challenges include elevating physiatry to become a global leader in biopsychosocial research, expanding the field’s role in population health, developing clinical models that best meet the needs of diverse populations, and providing global leadership in health policy decision making and disability rights advocacy.
Several important international trends have led to a shift in the demographics and characteristics of physiatric patient populations. Globalization has led to increased diversity of communities from the standpoint of culture, race, ethnicity, preferred language, and immigration status. In most World Bank high-income countries, populations are rapidly aging due to improvements in health care and reduced birth rates, resulting in an increasing prevalence of disability.11,12 These trends will challenge us to provide culturally competent rehabilitation services that meet the needs of highly diverse populations. It will also be important to continually educate the rehabilitation workforce to address the needs of a diverse and aging patient population.
The Increasing Global Need for Rehabilitation
More than 2.4 billion individuals globally are in need of rehabilitation services,13 highlighting the necessary evolution of rehabilitation medicine from a field focused on a relatively narrow population to a growing field addressing a profound worldwide healthcare gap. Physiatry must continue to expand its scope to address aging populations worldwide, to optimize the function of those who live with chronic disease, and to address the diverse and evolving contemporary causes of disability.13 Moving forward, it is important to expand the reach of physiatry by building local capacity in environments where physiatry is underdeveloped around the world. This should be done in collaboration with organizations that are already active in this space, such as the International Society of Physical and Rehabilitation Medicine and the World Health Organization.
Impact of Global Health Crises
The COVID-19 pandemic has demonstrated that global health crises will continue to impact communities. Long COVID has created a new category of patients requiring rehabilitation services, potentially similar to the historic impact of poliomyelitis or wartime injuries.14 Given physiatry’s interdisciplinary nature and holistic approach, the field has a prominent role to play in responding to crises by planning for patient recovery and disease reemergence. Responding to events such as natural disasters and pandemics demonstrates the impact of physiatry in providing high-value, cost-effective, and expeditious care.15 The lack of physiatrists and essential rehabilitation services in many world regions will result in additional vulnerabilities during times of crisis and underscores the need to strengthen and expand the role of physiatry in both international and local healthcare systems. The field of physiatry should be nimble, proactive, and prepared to embrace these challenges as they occur.
The Role of Rehabilitation in Population Health Management
Although the field of academic physiatry has historically focused on the diagnosis and treatment of injuries and illness at the individual level, there is tremendous potential for physiatrists to contribute to population health strategies. Given the mission to embrace a social model of disability according to the International Classification of Functioning, Disability, and Health,16 physiatry is well positioned to assess and help manage the impact of social determinants of health. In addition, many population health strategies emphasize the role of physical activity for health promotion and chronic disease prevention—a topic of physiatric expertise. Population health research is also increasingly aligned with global health priorities, which can inspire new directions of physiatric research with the potential for positive global impact.
Academic Physiatry and the Opioid Crisis
Although opioids can be a powerful tool to reduce acute pain and suffering among patients with certain medical and surgical conditions, chronic use of high-dose opioid medications and opioid use disorder have led to escalating death, disability, and hardship. The increasing prevalence of opioid-related morbidity and mortality in the United States and the threat of international opioid crises demonstrate the need for concerted action among physicians.17,18 Academic physiatry contributes to several efforts to prevent and ameliorate the problems associated with opioids.
The hazards of medical opioid use and the harms of excessive community availability of opioids can be diminished through common physiatric practices. Academic physiatrists are experts in the management of painful musculoskeletal and neurologic conditions and in safe opioid prescribing practices. Physiatrists have also been pioneers in interdisciplinary pain rehabilitation programs. Furthermore, many physiatrists are board certified in pain medicine, offering additional expertise in advanced procedures and medication management that can reduce suffering and the burden of opioid-related harm in our communities. Given their training and expertise, academic physiatrists have a crucial role and a clear opportunity to lead and contribute to the resolution of the opioid crisis.19
Health care is undergoing a technological revolution that will impact patient care, training, and research. Examples of these advances include sensor technology, enhanced health informatics, and brain-computer interface research. It is vital that cutting-edge rehabilitation services and technologies that are being developed at academic centers and universities are made widely available to the population, so as not to worsen preexisting inequities. As an example, the incorporation of precision medicine therapies and artificial intelligence (AI) support systems is becoming more prevalent in medicine. It is incumbent upon physiatrists to innovate and advocate for the use of these strategies for individuals with disabilities.
Virtual care—the practice of using remote technologies, such as phone calls, video conferencing, connected devices, and online chats to connect with patients—provides myriad opportunities for physiatry, including facilitating the functional and medical assessment of patients utilizing emerging wearable technologies. For example, the development and application of more effective haptic interfaces and related technology enhance the physical examination during a virtual encounter.20 It is likely that given factors such as the presence of virtual care pathways and remote options for monitoring and providing rehabilitation therapies, inpatient rehabilitation facilities will increasingly admit patients with greater medical complexity and disabilities. As AI provides physicians with improved clinical decision support, physiatrists will need to advocate for the inclusion of patients with disabilities into AI algorithms. In addition, decision support will be needed to guide and determine the feasibility and potential benefits of including robotics/exoskeletons, functional electric stimulation, and other novel therapies in home-based care.
Academic Medical Centers
While telehealth has survived the initial integration into academic medicine, the expansions of virtual care offerings will introduce new challenges to providers21 while expanding healthcare access for patients. The reach of academic medical centers (AMCs) may extend beyond the geographic constraints of local buildings, thereby improving the access of diverse and marginalized communities to the specialty care offered in these institutions. To capitalize on these opportunities, AMCs will need to be nimble to remain responsive to the needs of patients. Partnerships with industry and community practices will be important to continue to advance information technology infrastructure and clinically relevant rehabilitation technology. This will create new financial pressures that may increase costs and decrease margins. These financial pressures will need to be managed through increased efficiency of care as well as nontraditional revenue sources (e.g., accelerated commercialization of academic research and development products).
Data Collection and Analysis Tools
The increased availability of big data and real-time data from novel platforms will likely generate new research questions and accelerate the assimilation of new knowledge. Data from device integration and remote monitoring can facilitate both adaptive trial designs and the clinical translation of findings with greater ecological validity (i.e., when compared with in-laboratory or clinic measurements). Functional measurements from monitoring platforms can provide predictive analytics, broaden the use of physiatric principles in medical care across settings, and enable development of precision rehabilitation approaches to prevent or minimize the impact of disability. Wearables and mobile data collection systems also offer the potential to open new collaborations across systems.
AI and machine learning approaches can identify previously unrecognized contributors to impairment and disability,22 especially when combined with integration of expanded data (e.g., from remote monitoring and omics technology) within electronic health records. Novel targets for interventions and the enhanced ability to monitor outcomes have great potential to increase the impact of state-of-the-art approaches well suited to rehabilitation conditions, such as augmented reality and brain-computer interfaces, as well as to facilitate the development of precision rehabilitation.23
Medical education in an era of virtual care should be expanded to include training in patient monitoring and competency with new technologies. Curricula can benefit from exposure to data science and informatics, and educational assessment can be augmented by incorporating big data to track and improve individual trainees’ performance.24 The increasing availability of technology can facilitate the partnership of training programs across institutions in remote curriculum delivery and other collaborative learning models. The incorporation of interactive virtual education platforms will also likely become part of faculty development efforts for educators.
Access to Virtual Care
There remains a significant gap in the availability of physiatry services both in certain regions of the United States and globally. In this context, telehealth could improve access to high-quality physiatric care for individuals in rural and other underserved areas, as well as for those with disabling conditions that make travel to appointments more challenging.25 Expanding access to telehealth, however, will magnify disparities for individuals who lack access to appropriate technology, especially those who have communication, sensory, or cognitive disabilities. These challenges require creative solutions that can be generated and promoted by AMCs and community partners. An effective digital patient experience strategy will need to address the following goals: facilitated communication, ease of digital access for patients with accessibility needs (including low-cost, readily available devices), improving technical literacy, and a frictionless patient experience across the continuum of care.
DIVERSITY AND GLOBAL OUTREACH
Healthcare disparities and social determinants of health are important areas for curricular expansion in PM&R residency programs. Training programs and the entire field of PM&R will benefit from continued efforts to foster justice, equity, diversity, and inclusion (JEDI). There is opportunity to positively impact healthcare disparities and JEDI initiatives through global outreach and international collaborations.
Medical Education and Healthcare Disparities
Physiatric training will benefit from expanded curricular exposure to both healthcare disparities and social determinants of health given the service role and mission of AMCs and the impact of these disparities/determinants on rehabilitation outcomes. People with disability (i.e., stroke, traumatic brain injury, and spinal cord injury) from underrepresented backgrounds are negatively impacted by reduced access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance.26,27 Physiatric residency programs should illuminate care disparities by providing training on the social determinants of rehabilitation care and the disproportionate impact of disability and intersectional identities on health outcomes. Curricula and a healthcare disparity toolkit should be developed for residency programs to ensure that physiatry trainees receive sufficient exposure to these important issues and become equipped with mitigation strategies.
Diversity in PM&R
Compared with other specialties, medical school graduates entering physiatry are less racially and ethnically diverse.28,29 There is also a paucity of physiatrists from underrepresented minority groups at the rank of professor.29 Structural and institutional bias in academic medicine is a well-known barrier to the promotion of qualified persons in academia, especially at higher ranks.30,31 The AAP’s Diversity and Community Engagement Committee provides ongoing assessment of the systemic trends within the organization and its leadership structures (staff, volunteer, committees, and board members) to guide diversity and inclusion initiatives. The creation of programs to attract and retain individuals from marginalized groups in academic physiatry will help increase diversity within the field.
National physiatry organizations and PM&R departments should foster environments that prioritize JEDI throughout the field. Initiatives to address disparities should be inclusive of women, underrepresented minorities, persons with disabilities, and other marginalized groups. The development of curricula and resources that assist academic physiatry programs and departments with JEDI training will foster a more inclusive environment within our field. Training to recognize and address unconscious bias is important for physiatry trainees and faculty. As a result, some PM&R departments have created leadership positions (e.g., a diversity officer/liaison or vice chair) responsible for JEDI initiatives. Mentorship programs, such as that provided by the AAP for residency trainees and early career faculty, should consider diversity when recruiting mentors and mentees. Given that strong mentoring is associated with academic success and promotion, it is essential to mentor diverse trainees to ensure they reach prominence in the field physiatry.32 Furthermore, strategies to address the paucity of underrepresented groups at the rank of professor should include sessions on criteria and support for promotion, development of faculty promotions criteria that value JEDI work, and diverse promotion committees.
The core mission of academic medicine has become global as US healthcare systems expand their clinical reach to international contexts.33 Physiatrists in the United States therefore have extensive opportunities for international outreach and collaborations. There are few studies or reviews that compare rehabilitation care across different countries. In addition, little is known regarding the differences and similarities between residency training programs in different countries. Studies of differences across countries could guide opportunities for physiatrists to share knowledge and resources. Highlighting differential global access to rehabilitation care and differences in practice patterns (e.g., the formation of organized international electives with exchanges across countries, as well as educational lecture series from international faculty that would be broadcast to US physiatrists and vice versa) could enrich PM&R residency training. Curricula and resources should be made available to facilitate the exchange of ideas between academic physiatrists from different countries. National and international organizations such as the AAP and International Society of Physical and Rehabilitation Medicine have started to facilitate these opportunities for collaboration.
Changes in US healthcare policy and delivery models have necessitated ongoing changes in academic physiatry. Changing reimbursement models, the pandemic, and inflation have led to financial pressures on PM&R department budgets. Although clinical care continues to be the largest source of revenue, research funding is an important aspect of academic PM&R departments.
Healthcare Policy and Reimbursement
Historically, changes in the models and methods of healthcare delivery and the accompanying economic reimbursement have had an enormous impact on academic medicine, including academic physiatry. In recent years, several important trends have emerged in the United States, including the expansion of Medicare and increased access to health insurance through the Affordable Care Act. In some areas, a shift has begun from fee-for-service to value-based programs rewarding quality of care rather than quantity of treatments. Increased access to care and value-based programs present opportunities for physiatry to take a leading role in team-based care focused on improving function and quality of life outcomes.
Meanwhile, payors continue to push cost control strategies such as the increased provision of care outside the hospital setting (e.g., ambulatory clinics and outpatient surgical centers) and at less costly post–acute care settings (e.g., subacute or transitional care). Hospitals are also delivering increasingly more complex, specialized care. As a result, inpatient rehabilitation facilities are being challenged by the necessity of caring for patients with increased case complexity. In light of these changes, physiatrists should continue to expand the scope of their inpatient activities outside the traditional inpatient rehabilitation units or other inpatient rehabilitation facility–based settings. Physiatrists should leverage opportunities throughout the continuum of care, with the goals of facilitating prehabilitation, preventing secondary complications, minimizing the development of disability, and reducing hospital lengths of stay and the number of readmissions.
Academic Department Revenue Sources
Traditional sources of revenue for academic departments and units have included reimbursement for clinical activities, research activities (e.g., grants and contracts), tuition (e.g., physical therapy academic programs within PM&R departments), and philanthropy. Although endowments are an additional revenue source, these are typically earmarked for capital or structural projects and less often for the sustainment of ongoing operations. As clinical reimbursements have generally failed to keep pace with inflation, the operating margins for departments have shrunk. Lean operating budgets have made it more challenging for academic departments to support protected academic time for activities such as teaching and scholarship, unfunded research, service, and administrative activities that are not revenue generating. These challenges have been compounded recently by pandemic- and inflation-related financial pressures faced by AMCs.
Increasing financial pressures can create tension within academic departments between members engaged primarily in producing clinical or grant revenue and those focused on academic activities consistent with departments’ mission and values that generate less or no revenue. This is partially attributable to the need to redistribute funds to support the full scope of department activities, as some areas critical to the function of the department might not be reimbursed at financially viable levels. Given current trends, some academic institutions have responded by partnering or merging with other private and public organizations, forming large healthcare networks that can benefit from economies of scale and increasing clinical revenue. Trends toward consolidation have been further enhanced by the challenges that smaller organizations face in adapting to and meeting increasing regulatory requirements. Increasingly, recent graduates are deciding to join larger networks. Many established solo practitioners and smaller private practices are merging with large healthcare networks, resulting in the need to adapt and adjust to different professional cultures.34,35
Research is vital not only to the field of PM&R (e.g., driving innovative and impactful treatments including personalized medicine approaches, providing evidence for existing rehabilitation strategies to ensure continued payor reimbursement) but also to individual departments. Research grants can provide revenue (usually through a portion of indirect costs that flow back to the department) and can pay for portions of departmental faculty and staff salaries as well as equipment. In addition to these direct financial benefits, funded research also enhances the reputational impact of departments which can indirectly provide additional revenue by attracting more patients and by inspiring philanthropic donations.
There is a relative dearth of physician-scientists in PM&R. Although gains in the quantity and quality of physiatric research have been achieved with the help of programs focused on generating and training the next generation of physiatric scientists, such as the Rehabilitation Medicine Scientist Training Program,36 PM&R still lags behind other related fields in research funding. For instance, there are more than three times as many neurology departments as PM&R departments with National Institutes of Health funding and neurology as a field has more than 10 times as much total National Institutes of Health funding compared with PM&R.37 Although research funding from a variety of sources (e.g., federal grants through National Institutes of Health, Department of Defense, National Institute on Disability, Independent Living, and Rehabilitation Research, Department of Veterans Affairs, Patient-Centered Outcomes Research Institute, foundations grants, and industry funding) is important, National Institutes of Health funding is often considered a key benchmark of research success in academic institutions. There continues to be a critical need to support and expand research capacity in PM&R through national training programs such as the Rehabilitation Medicine Scientist Training Program and through the AAP Research Consultation Program, which can help expand the number of academic departments with successful researchers who can act as scientific mentors to trainees and junior faculty.
Example of a Funding Model Outside the United States (Canada)
Models of funding for academic medicine, including physiatry, differ outside the United States and provide examples of delinking fiscal support for academic activities from clinical revenue. In Canada, for instance, many provincial governments earmark funding specifically to academic health science centers to support nonclinical activities, such as teaching and scholarship (e.g., research). In Ontario for example, the Ministry of Health funds a negotiated number of residency slots (specific to each specialty). Because funds are not tied to an individual hospital, residents can rotate to the sites that offer the best educational opportunities. Additional funding is provided to AMCs through a negotiated contract between an Academic Health Science Centre and the Ministry of Health. This mechanism supports academic activities such as teaching and research in exchange for specific identified academic deliverables (metrics).
In Canada, postgraduate fellows are often self-funded, as they can bill for clinical care at the level of attending physicians (similar to non–Accreditation Council for Graduate Medical Education accredited fellowships in the United States). Clinical fellows can therefore be a source of revenue for academic practice plans, as generated revenue typically exceeds the negotiated salaries for fellows. Physiatry fellowships in Canada do not lead to accredited subspecialty certification, but they carry academic prestige and can facilitate academic appointments. Analogous to the United States, sources of funding for research include private foundations and government agencies such as the Canadian Institutes of Health Research. For most Canadian Institutes of Health Research grants, however, funding of investigator time (commitment) is not permitted, and other sources of funding must be found.
High-quality physiatric training is important for developing strong future physiatrists to meet the needs of the large and growing segment of the population with disabling conditions. A recent workforce modeling study concluded that the United States will continue to have a persistent shortfall of physiatrists unless there is a sufficient increase in physiatry residency and fellowship positions.38 Furthermore, geographical imbalances continue to exist in part owing to the limited PM&R training opportunities in some areas of the United States (e.g., especially in rural areas).38,39 In addition to expanding the number of residency and fellowships positions, physiatric educational programs must be flexible and focused on the success of current and future physiatrists. Thoughtful and focused educational initiatives ranging from clinical knowledge to administration and leadership skills will help academic physiatrists navigate the challenges of the future, ensuring the relevance and impact of the field.
Depth and Breadth of Education
Increasing numbers of physiatry residents enter one of the seven subspecialty fellowships sponsored by the American Board of Physical Medicine & Rehabilitation. Although the breadth of physiatric practice is a strength of the field, it can be challenging for PM&R residency programs to provide sufficient subspecialty exposure while maintaining robust education on “core” physiatric principles. Academic physiatry should highlight practice and educational gaps, such as when there is a need to incorporate new technology or to address expansions in physiatric practice (care locations, competencies, skills, or knowledge).
Recruitment Into PM&R
Strategies for recruiting excellent and diverse physiatric residency candidates are vital to sustaining a profession of committed and high-quality physiatrists. A holistic review of the candidate’s application should be implemented to reduce unconscious bias during the recruitment process. Making meaningful connections with potential candidates before and during medical school through special interest groups, physiatrist leadership in medical school curricula (didactic and skills based), and AAP-led medical school curricula in disability, function, and interprofessional teamwork will serve as an introduction to the field for many and solidify interest for others. Outreach from academic and community physiatrists into medical schools without physiatrist faculty members must be prioritized. Similarly, reaching out to medical schools that traditionally have attracted minority students will be critical to increase the potential number of students from these groups interested in PM&R. Rotation opportunities should be expanded, especially with outreach to those medical schools without PM&R clinical programs or academic departments. Creative approaches, such as virtual clerkships, can expand trainees’ access to physiatry departments across the globe.
Residency Program Virtual Recruitment
The rapid adoption of virtual residency recruitment has enabled residency candidates to apply and interview more broadly. This system may reduce economic inequities for both applicants and programs. However, the increase in number and breadth of applications threatens the ability of programs to efficiently identify strong applicants that are likely to rank the program and enable a successful match. “Preference signaling” for applicants, which will begin in 2022, allows applicants to indicate preference for a limited number of programs and allows programs to tailor limited interview opportunities accordingly if desired.40 This strategy reduces the need for programs to use less reliable and potentially biasing strategies to determine applicant interest.
Widespread Virtual Curricula
The adoption of virtual meeting platforms in educational venues has enabled educators to reach national and global audiences, both synchronously and asynchronously. Virtual education presents opportunities for national and international experts to provide foundational and advanced physiatric education (e.g., through virtual residency didactics, national grand rounds). Academic physiatry should sculpt a culture and framework for quality review of virtual teaching materials targeted to learner needs. This process would benefit from formally attributing scholarly value to high-quality educational materials targeted for wide dissemination and in turn incentivize the development of virtual educational resources.
The recent rapid growth of telehealth presents an opportunistic environment to which our educational precepting model should adapt. Opportunities include development of standardized and targeted virtual physical examination components, as well as guidelines for recreating informal spaces between clinical encounters for preceptors and trainees to connect, mentor, and teach. The virtual setting also offers unique opportunities for preceptors to directly observe learner-patient interactions without interrupting the clinical encounter. There would likely be benefit to (1) customizing a curriculum in which clinical skills for virtual and in-person venues are taught simultaneously and purposefully and (2) developing a virtual staffing model optimized not only for patient care but also for preceptorship and coaching.
Advanced Practice Providers Education
The role of advanced practice providers (APPs) in physiatry and in health care in general is expanding. The physiatric focus on team-based care lends itself to the inclusion of APPs. Many APPs complete training without significant exposure to the field of PM&R; therefore, an intentional and robust educational program is needed to ensure the delivery of safe and high-quality care. Incorporating APPs into existing PM&R educational programs, 1:1 mentoring, and access to local and national PM&R conferences can provide opportunities for APPs to expand their knowledge of the field.
This environmental scan explored challenges and opportunities within five key themes, which can support decision making and strategic planning for the field of academic physiatry. To thrive within complex and evolving healthcare systems in the United States and globally, the field must respond dynamically and proactively to both challenging unpredictable events and emerging opportunities. Globalization and an aging population with increased prevalence of disabilities present academic physiatry with opportunities such as developing clinical models that best meet the needs of these diverse populations, providing global leadership in biopsychosocial research, reducing disparities in rehabilitative and post-acute care, and championing disability rights. Technological advancements (e.g., virtual platforms, remote monitoring, brain-computer interface, ubiquitous measuring, AI, omics, and big data mining) also offer opportunities for enhanced and broader physiatric clinical care, training, and research. The current COVID-19 pandemic is a great example of a disruptor that presents critical challenges yet offers unique opportunities to the field of PM&R. Positive change inspired by these challenges includes expanding telerehabilitation services, developing physiatry-led comprehensive care for an expanding long-COVID population, and developing virtual educational offerings. Continued development of these opportunities within academic physiatry will ensure a balanced approach that can reach all groups while maintaining a focus on the interests of the patients that we serve.
We can be certain that our society and healthcare system will continue to be presented with new challenges. For the field of academic physiatry to continue to thrive and lead, it is vital that opportunities for innovation and positive impact within these challenges are identified as they arise. To this end, it is imperative that our field remains consistently self-reflective, forward-looking, creative, proactive, and thoughtful in our approach.
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