Interviewed by Brandon Barndt, DO
Elizabeth (Beth) Pegg Frates, MD is a pioneer in lifestyle medicine education, is an award-winning teacher at Harvard, and currently works with patients to help them adopt and sustain healthy habits. Since 1996, Dr. Frates has been on faculty at Harvard Medical School and has won multiple teaching awards, and, most recently, she created the first full-semester lifestyle medicine course at Harvard, which was recognized by the University as an example of a successful course offered at the Harvard Extension School. She serves as the Co-Chair of the Pre-Professional Education Committee at the American College of Lifestyle Medicine (ACLM) and was elected to the Board of Directors for the ACLM for a three year term ending October 2019.
She has co-authored two books on Lifestyle Medicine: Life After Stroke: The Guide to Recovering Your Health and Preventing Another Stroke and The Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits.
Currently, Dr. Frates serves as the Director of Wellness Programming at the Stroke Institute for Research and Recovery at Spaulding Rehabilitation Hospital. Dr. Frates sees patients through her private practice, Wellness Synergy, LLC. Merging her training in physical medicine and rehabilitation with her training in lifestyle medicine and coaching, Dr. Frates has developed novel wellness programs for stroke survivors and their caregivers based on lifestyle medicine principles (nutrition, exercise, stress reduction, connection).
She graduated from Harvard College and then then attended Stanford Medical School, interned at Mass General Hospital, and completed her residency in the Department of Physical Medicine and Rehabilitation at Harvard Medical School where she served as Chief Resident.
Q: Lifestyle medicine is a very new field within medicine. Can you tell us a little bit about what Lifestyle medicine is, in your mind, and what your favorite aspect of it is?
Lifestyle Medicine is an evidence based burgeoning area of medicine that uses healthy habits like regular exercise, nutritious eating patterns, sound sleep, stress reduction, and cultivating high quality connections to help prevent, treat, and even reverse medical conditions and diseases like diabetes, heart disease, obesity, and high blood pressure.
My favorite part about lifestyle medicine is the challenge of helping to empower people to not only adopt healthy habits but also to sustain them. Tapping into a person’s motivators for change is key. Using motivational interviewing skills allows the lifestyle medicine physician to encourage the patient to talk about all the reasons that the patient would benefit from change and why that change might be important to that particular person. It is a patient-centered approach. There are guidelines for exercise, diet, and sleep, but not everyone will be able to meet the guidelines right away. So, the lifestyle medicine physician must collaborate with the person to find the best individual approach that will get the patient moving in the right direction. What works for one person may not work for someone else.
Q: You are a physiatrist by training, so how did you come to get involved with Lifestyle Medicine? Do you feel like Physical Medicine & Rehabilitation and Lifestyle Medicine mesh well?
I was very interested in stroke and stroke prevention as a pre-med student. My father had suffered a stroke when he was 52 and I was 18. I watched his recovery and his complete lifestyle change. He often said he lived the best 27 years of his life after his health set back. So, I went into medicine knowing I wanted to help people prevent heart attacks and strokes, but in the 1990s there was really no field that focused on prevention in this way. Preventive Medicine was mostly epidemiology at that time. Physiatry training seemed like a great fit, so that I could focus on stroke and recovery. Rehabilitation uses exercise prescriptions and nutrition prescriptions routinely. However, it was not until I co-authored a book titled Life After Stroke: The Guide to Recovering Your Health and Preventing Another Stroke, that I really took a deep dive into the power of exercise and nutrition in preventing strokes (primary and secondary prevention).
When I was a resident at Spaulding Rehabilitation Hospital, Dr. Eddie Phillips was an attending. He knew about my stroke prevention book and told me that I had written about lifestyle medicine. At that time in 2009, he asked me to join him in creating the Institute of Lifestyle Medicine which offers CME courses twice a year at HMS in lifestyle medicine. I worked with Dr. Philips to put those courses on for almost 10 years. Then, I started to attend the American College of Lifestyle Medicine annual meetings and met lifestyle medicine leaders from across the country including Dr. Dean Ornish and Dr. David Katz. I was voted to the Board of Directors for the American College of Lifestyle Medicine and got very involved in the Education efforts there.
Since I had created an entire 14-week course titled, “Introduction to Lifestyle Medicine” for the Harvard Extension for the undergraduate and graduate level courses in the Psychology Department there, I had developed a framework for teaching the materials. There are 6 pillars in lifestyle medicine: exercise, nutrition, sleep, stress resiliency, social connections, and substance use moderation or elimination. The Harvard Extension School course covered all these pillars and more. Behavior change is an important aspect of lifestyle medicine, and in the course there are two weeks devoted to empowering people to change. Other topics included are mindfulness, meditation, and mindfulness-based stress reduction, positive psychology, and the importance of self-care.
Thinking about the 6 pillars of lifestyle medicine and the other topics I teach in the Lifestyle Medicine course at the Harvard Extension school, one can identify significant over-laps and synergy with rehabilitation medicine. Lifestyle medicine is usually practiced in a team much like physiatry. A lifestyle medicine team includes a nurse, a doctor, an exercise specialist, a nutrition specialist, a behavior change specialist, and sometimes a social worker or other allied health professionals. Physiatrists are accustomed to working in teams and holding team meetings. Lifestyle Medicine physicians need to be able to do the same.
Q: So, it sounds like Lifestyle Medicine is quite the exciting field and has grown quickly! How has the field evolved over the last 10 years?
The field has evolved a great deal over the years. In terms of research, the number of papers about exercise, diet, sleep, and stress resiliency techniques has grown at a rapid rate and continues to do so. Dr. Dean Ornish has performed important studies demonstrating that a lifestyle medicine approach including exercise, healthy food, yoga, and social connection can help to reverse cardiac disease. His research is so robust that now in 2019, his UnDo It Program is covered by insurance. This is good news because hopefully more and more lifestyle medicine programs will be covered.
Three years ago, the American Board of Lifestyle Medicine was created. And, now there is a certification process for physicians and other healthcare providers to become certified in lifestyle medicine. This is a big step forward as it allows the field to have a scope of practice and some uniformity with regards to clinicians’ knowledge and treatments.
More and more medical schools are starting to incorporate lifestyle medicine into their curriculum. Most programs are reviewing the existing curriculum and looking for ways to add lifestyle medicine cases, research, and guidelines into subjects that are routinely covered like physiology, endocrinology, and cardiology. This is happening right now at Harvard Medical School. Some schools are offering electives in lifestyle medicine. Harvard offered their first elective last spring, and it was a great success.
In 2009, I started the first lifestyle medicine interest group (LMIG) at Harvard Medical School. This is an opportunity to offer a parallel curriculum to students during lunch time. With this approach, the core curriculum does not need to be altered and administration does not need to be involved with making any changes. An LMIG meets during the week usually at lunch. Professors with an interest and expertise in exercise, nutrition, sleep, and behavior change give presentations while students eat lunch. The Harvard group has been running for 10 years and serves as a model for other schools. I worked with the American College of Lifestyle Medicine and their Professionals In-Training group 4 years ago to help create programming that would enable medical school faculty from across the country to start these groups. I shared 4 PowerPoints that are free and easy to download off the ACLM website. In addition, there are 4 Donald A Pegg Awards given at the ACLM annual meeting. These awards are $1,000 monetary value each to help medical students and faculty to start LMIGs and to help students attend the national meeting.
The American Journal of Lifestyle Medicine has also grown and evolved. It is now featured in PubMed.
Q: You are a very active and prominent member of the Lifestyle Medicine community. Do you mind sharing some details about any projects that you are currently working on or are soon to be released?
I have been actively involved in the education committee at ACLM. In 2018, I co-authored The Handbook of Lifestyle Medicine: An Introduction to the Power of Healthy Habits in collaboration with ACLM. This handbook can be used as the textbook for courses in college or graduate schools. In addition, patients enjoy reading it as it has “Live and Learn” cases in each chapter that describe a patient’s story. Each chapter has the guidelines, research and benefits to the 11 systems of the body for each of the 6 pillars in lifestyle medicine. In 2017, I shared my syllabus from the Harvard Extension School course with ACLM. And that is freely available and downloadable from the ACLM website. Most recently, over the past year, I collaborated with colleagues at ACLM to formalize and standardize a set of 12 PowerPoint decks (120-200 slides per deck) so that college professors, and graduate school professors, as well as community educators could use the set of PPTs as a course on lifestyle medicine. This should be available for release the fall of 2019.
Interviewed by Brandon Barndt, DO and Austin Marcolina, DO
Zachary Bailowitz, MD, is a Physiatrist and Primary Care Sports Medicine physician in the Department of Orthopedics at Kaiser Permanente in Oakland, CA. He attended medical school at the University of Arizona College of Medicine in Tucson, AZ, and residency in Physical Medicine and Rehabilitation (PM&R) at Carolinas Rehabilitation in Charlotte, NC, before completing a Sports Medicine Fellowship in the Department of Rehabilitation and Regenerative Medicine at Columbia University in New York City.
Q: For starters, tell us your path to where you are today. How did you learn about PM&R, and more importantly, what drew you to the specialty?
Before I even knew about physiatry, I worked with my uncle, who was a chiropractor who treated athletes. He was always learning and teaching me about function in athletes and to evaluate the way an athlete moves not just their injury, and it inspired me to be interested in a career in musculoskeletal medicine. Then during 1st year of medical school I was lucky enough to attend the medical student portion of the AAPM&R annual assembly, and I knew from that brief conference that physiatry was the right field for me.
Q: Were you involved in leadership organizations, extracurricular activities, or research while in residency? Would you mind divulging into some of what you were able to accomplish?
As far as leadership, I was nominated to be on the AAPM&R PHiT council, which I served on during a PGY3 and as a Fellow. This was a great experience to learn more about the national leadership of the Academy as well as get a better understanding of where the field of physiatry is moving. I also was the chief resident at Carolinas Rehabilitation, which was a great way for me to help teach, lead, and improve my residency program.
As far as extracurricular activities, most of my time was spent doing sports coverage, as I knew I wanted to pursue a fellowship in Sports Medicine. I worked at the Charlotte Marathon and was involved with the adaptive sports program in Charlotte. I also worked with the special Olympics and ran one of our biannual medfest events to screen disabled athletes. But perhaps my favorite experience was being the team physician for a local high school football team during my 4th year of residency. This was so rewarding to be on the field each week and able to see the kids on a regular basis.
In terms of research, I did multiple projects surrounding EKG screening as part of the pre-participation exam for athletes. This is a very hot topic right now, and it was great to be a part of this discussion in a meaningful way. My colleague and I also created a novel technique for evaluating patellar tracking using musculoskeletal ultrasound, and we’re continuing that research now that I’m in my fellowship and plan to finish in the coming years.
Q: Was it always your plan to pursue sports medicine as a career, or something you realized while in residency?
I always knew I liked the idea of treating athletes in clinic, as I felt they were some of the most motivated patients to work with. However, during residency, I began to realize that there is a difference between seeing musculoskeletal patients in clinic and actually doing sideline coverage and training room coverage where you see the injury in its hyperacute stage. Seeing the entire spectrum of an injury is something I’ve really come to enjoy, so I made the decision to go for full accredited sports medicine fellowship during 3rd year of residency.
Q: What is your favorite aspect of sports medicine?
As a physiatric sports medicine physician, I often see the more complicated and challenging cases. I like using my background in physiatry and my knowledge of the spine, peripheral and central nervous system, and the musculoskeletal system to make the most accurate diagnosis for the patient and hopefully get them back to their sport as quickly as possible.
Q: How do you see the fields of PM&R and sports medicine changing within the ever-changing landscape of healthcare?
I believe sports medicine will become more procedural as time goes on. As more and more midlevel providers join our hospital systems, the day to day of seeing patients in clinic may take a back seat to team coverage and ultrasound/fluoroscopic guided injections. PM&R doctors, though, are in a unique position since we have such a wholistic approach to musculoskeletal pathologies. Always making sure to keep your history and physical exam skills sharp will ensure that you will be a cut above the average musculoskeletal provider.
Q: As there are fellowships from both physiatry and family medicine departments, could you describe the differences between the two types of fellowships?
This is not easy to answer as many programs, whether they’re based in departments of PM&R, family medicine, or other (ER, peds, internal medicine), have specifics that make them unique. However, all sports medicine programs have to meet ACGME requirements, so I would imagine there are more similarities than differences.
In general, family medicine programs may have more focus on the overall medical care of the athlete (cardiology, pulmonology, etc.) while PM&R programs may focus more on musculoskeletal and spine care of the athlete. However, this is highly variable and depends greatly on the faculty and the institution. PM&R programs are more likely to offer opportunities to do interventional spine injections, but those opportunities may also exist at other programs. Family medicine programs may have increased exposure to pediatric patients.
My best advice when trying to decide between programs is to look into the specifics of the individual program and figure out what aspects are important to you. I would base it less on the department and more on the specific faculty, interests, and focus of the program itself.
Q: What does a week in the life of a PM&R-based sports med fellow look like?
My week was pretty variable, which was one of the most exciting parts of it. In general I would spend about 8 half days total in clinic, which would vary between general MSK clinic, sports medicine clinic, and continuity clinic in my primary specialty. I spent a ½ day each week in the Columbia University training room where I was evaluating mostly non-MSK pathologies of the university athletes. This was a great opportunity for me to round out my sports medicine education and help me prepare for the boards with all of the non-MSK aspects of treating athletes. Then I had a ½ day of academic time where I could focus on research, teaching, and other administrative responsibilities. The remainder of my week was highly variable depending on the season. I would typically have 1-2 sports coverage opportunities each week, would be helping out with pre-participation physicals, or after-hours ultrasound teaching with residents.
Q: Now that you have finished your fellowship, where are headed to and how has your perspective changed?
I am heading to Oakland California where I’ll be one of 4 primary care sports medicine doctors in the Ortho department at Kaiser, Oakland.
As I was going through the process of interviewing and eventually accepting a position, I think the biggest thing is going to a fellowship that is flexible and exposes you to many aspects of sports medicine. The job market is variable from year to year and it’s important to be able to make yourself marketable to multiple types of practices (private, academic, etc). My fellowship was very flexible and allowed me to pursue multiple interests, which ultimately made me a better candidate for the different jobs I pursued.
Q: What resources/activities would you recommend for those interested in a PM&R-based sports medicine fellowship?
The American Medical Society for Sports Medicine (AMSSM) is a fantastic resource for all things related to sports medicine fellowships. There you can find descriptions of various fellowships, educational tools including phenomenal ultrasound videos, and dates of upcoming conferences. I would recommend that anyone wanting to go into sports medicine attend the AMSSM annual conference at least once during residency. The AAPM&R also has some resources on its website about pursuing a sports medicine fellowship. But honestly the best resource for me was to speak with various sports medicine physicians of multiple backgrounds, whether that’s PM&R, family medicine, or another background. I learned so much about the field of sports medicine as a whole just by talking with current fellows and physicians, and I’d be happy to speak with anyone that is interested!
Interview by Austin Marcolina, DO
Since PM&R is a relatively small field, how did you first learn about the specialty and were there any specific characteristics that drew you to PM&R and then interventional spine?
In third year of medical school, like many students, I was constantly changing my mind about what field to pursue. I was initially interested in sports medicine and pain medicine. I first rotated through various specialties including family medicine, ER, and internal medicine, as well as anesthesia-based pain medicine. When weighing the pros and cons of each specialty, I was speaking with a family medicine-trained, sports medicine physician at U Penn who suggested that I look into PM&R. This physician knew I was interested in the musculoskeletal system, but was wavering on whether or not I wanted to undergo the broad-based training of family medicine residency. I then rotated with Dr. Chris Plastaras, who at the time was running the U Penn Spine program, and that really clicked with me. From there, I did more rotations that covered the true breadth of the field. The fact that the field focuses on functionality and the whole person really drew me to pursue further training in PM&R.
While in residency at RIC/Northwestern, I continued to explore the options between sports medicine and interventional spine/pain medicine. I ultimately felt most engaged by the complexities of diagnosis and patient management, as well as the more prominent procedural focus, in the spine/pain medicine niche.
What are some of the common conditions you treat in an interventional spine practice? What does a day in the life of an academic interventional spine physician look like?
This varies significantly between physicians, but for my practice specifically, I see everything along the acute to chronic spectrum, from acute back/neck pain due to disc herniation to chronic pain after remote spinal fusion with adjacent segment degeneration and multiple failed treatments. While we have great spine surgeons here at the University of Utah, inevitably some patients will fail surgery and require other modalities for their spine-based pain. Outside of our institution, in the Salt Lake City region, a large number of spine surgeries are performed, so I probably see more of the chronic, so called "failed back surgery" patients than most interventional spine physicians.
As an academic physician, I actually have wonderful balance. In regards to my practice, I spend approximately 70% of my time on clinical care and 30% of my time is split between research, administrative duties, and teaching. For the research component of my practice, we have a great team composed of attending physicians, clinical research coordinators, a biostatistician, fellows, residents, and students who assist in projects, including clinical trials and large data mining studies. At the end of the day, you can carve out any split of duties you desire within academics. There are positions that are significantly more research-based than mine, and there are others that include minimal research. It is a common misconception that academic positions require consistent procurement of significant grant funding and a robust research component; this is simply not the case. The key is finding your niche and exploring opportunities that are consistent with your career goals.
As you completed your training in an ACGME-accredited pain medicine fellowship and now are the director of an interventional spine and musculoskeletal medicine fellowship, you seem to have unique insight in regards to the similarities and differences between the two. For those that may be considering both types of fellowships, how would you differentiate the knowledge and skills learned between the two fellowships? Are there specific instances or patient populations that may be better served by one over the other?
There is clearly going to be a significant amount of overlap between the two fellowships and eventual practices, as the diagnosis and treatment of spinal pathology is common to both fields. Of course, within pain management, you will see a wider variety of pain conditions, including: headache, facial pain, peripheral/neuropathic pain, and the like. During the pain medicine fellowship itself, you will spend more time with other services, such as palliative care, psychiatry, neurology, pediatrics, etc., as the goal is to develop as a broad-based multidisciplinary pain specialist. For patients that have a significant behavioral component to their experience of pain, they are best served multidisciplinary pain programs, sometimes also known his functional restoration programs. This is a necessary part of training in any strong Pain Medicine fellowship where the goal is to finish training as a well-rounded provider. A great example of this is RIC/Shirley Ryan AbilityLab multidisciplinary pain program. It is rare for behavioral pain management to be integrated into an interventional spine fellowship or into an interventional spine practice.
Every interventional spine fellowship is going to be a bit different, primarily due to the fact that, historically, there was not as much structure associated with these fellowships. For example, when considering ACGME pain fellowship programs, the are specific guidelines in place that dictate what each fellow needs to accomplish by the end of their year (ex.: psychiatry, acute pain, pediatric pain, etc.). However, this discrepancy in structure between Pain Medicine and Interventional Spine Fellowships is changing. The North American Spine Society (NASS) has begun to recognize spine fellowships, and the tentative plan is that these fellowships will be accredited by an organization other than the ACGME, similar to many orthopedic surgery subspecialties. The plan is that NASS will recognize a fellowship if it meets specific standards set by NASS leadership. Through this process, high quality Interventional Spine Fellowships will be recognized for both their curriculum and commitment to academics. Currently there are approximately 15 fellowships that are recognized by NASS, including our program at the University of Utah.
In regards to Interventional Spine fellowships in particular, these will generally be more focused and provide more in-depth training related to diagnosis and management of spinal pathologies. For example, in our program, there is an expectation that fellows exit fellowship as experts in spinal imaging. While not to the same degree as a diagnostic radiologist per se, the fellows should be comfortable in interpreting everything from plain films to CT scans and MRIs, due to the amount of time that is allotted with neuroradiologists and attending physicians interpreting imaging both in clinic and during procedures. This is generally the case with high-quality Interventional Spine fellowships as opposed to most Pain Medicine fellowships. There is also more allotted time to be spent with spine surgeons, in order to obtain a better understanding of the nuances of surgical indications and how to properly manage post-spine surgery patients over time. From personal experience, interventional spine physicians typically see a larger percentage of these postsurgical patients than I did in pain fellowship. Neuromodulation (i.e.: spinal cord stimulators) is also something that most interventional spine fellows should be comfortable with, as one of the primary indications for this modality is failed back surgery syndrome. Neuromodulation is used widely in Pain Medicine as well, so this is not necessarily a differentiating factor between the two types of fellowships. However, this is where the differentiation of individual fellowships of the same type becomes more noticeable, as there are some pain fellowships that have a large amount of exposure to neuromodulation, while there are others that are a bit lighter on exposure. Finally, a key part of an interventional spine fellowship, and this is especially notable with the University of Utah fellowship, is the amount of time spent with physical therapists. As opposed to a Pain Medicine fellowship, where time with physical therapists is limited, this is an essential component of a good spine fellowship, as understanding how appropriate physical therapy works is a great “tool in the toolbox” for interventional spine attendings.
One aspect that is readily evident when speaking with you is your drive for research. As someone with over 100 publications and current Director of Clinical Spine Research at the University of Utah Division of PM&R, how did you first become involved with research? How do you manage the schedule of a busy clinical practice in addition to ongoing research projects? Do you have any advice for residents/medical students in regards to becoming an efficient and effective researcher?
I actually started out as more of a basic scientist. I completed a thesis in developmental T-cell immunology during undergrad, and I continued rat/mouse model research through medical school. It was not until the end of medical school that I started learning more about clinical research, and this is when I began to transition my focus. What I have found is that if you enjoy being a clinician, there is great synergy between clinical practice and clinical outcomes research.
Research is a team sport. It is much more enjoyable and effective when working with collaborators that have curious minds and also want to advance science. These days, I spend much more time organizing and leading teams than I did in the past. While I still spend quite a bit of time with research design, grant writing, and editing manuscripts, it takes a team to move all of our projects forward. In my opinion, it’s more fun and rewarding to share in the successes together (as a group).
For medical students and residents, the most important thing to do is to find strong mentorship. This does not have to be one person. Over the course of my career, I have had numerous mentors. It is important to remember that every mentor can contribute something different to your education and development. The goal is to find people that are truly interested and invested in helping you to grow. Another key component is to read the primary literature. While textbooks are fine for basic or foundational knowledge, they will not keep you up-to-date on new advancements or the most current knowledge gaps. Reading primary literature will also expose you to elements of study design and science writing, both good and bad. Make sure to ask your mentors what to read - the classic papers and recent meaningful papers that are changing practice.
Do you have any advice or resources for residents that may be considering a career as an interventional spine physician or medical students interested in PM&R?
The AAPM&R has a ton of great resources for those interested in physiatry as a whole and all of the specific sub-specialties. For those already interested in interventional spine, pain medicine, or both, I would recommend becoming a member of the sub-specialty societies (NASS, SIS, AAPM), as membership is typically free or low cost for trainees. Another way to truly immerse yourself within a field is to attend conferences and workshops. During these meetings and labs, you will be able to hear from and speak to the thought-leaders within each field. These interactions can be invaluable in obtaining a better understanding of how each field is moving forward and what types of opportunities are available.
Kritis Dasgupta, MD, MBA, MSc is the Chair of Physical Medicine and Rehabilitation at MedStar Good Samaritan Hospital. He also serves as the Associate Medical Director for the MedStar National Rehabilitation Network, Baltimore region. Dr. Dasgupta was at MedStar National Rehabilitation Hospital (NRH) for nearly 10 years and served as the Medical Director of the Brain Injury Program and Medical Director for Quality and Safety. He obtained his undergraduate degree in English from Princeton and his medical degree from the University of Maryland. He holds an MBA from Johns Hopkins and an MSc in Evidence-Based Health Care from Oxford.
Originally interviewed by Dr. Mike Farrell in November, 2016
How did you become interested in medicine, and specifically, what attracted you to the field of Physical Medicine and Rehabilitation (PM&R)?
I enjoyed science and problem-solving, and also enjoyed interacting with people. I was an English major in college but did not think becoming an English professor was the right path for me. Medicine seemed to have the right balance of human interaction and technical knowledge.
As a freshman in medical school I read that PM&R physicians are among the happiest with their choice of specialty. I did two PM&R rotations as a fourth-year medical student and enjoyed them very much, specifically the intimate relationship with patients and the collaboration of working with a rehabilitation team. I liked the rehabilitation environment of positive encouragement and kindness. I also had a longtime passion for the martial arts, which fit well with PM&R’s holistic and exercise-centered approach.
Could you tell us about your work in Traumatic Brain Injury (TBI), and what kinds of medical problems and conditions you address in practice?
As an inpatient brain injury physician I work closely on a team with physical, occupational, speech and recreation therapists, social workers and psychologists. The patients I encounter have had traumatic brain injury from falls and accidents, non-traumatic intracranial bleeds, brain tumors and even conversion disorder with neurological-appearing symptoms.
Chronic Traumatic Encephalopathy or CTE has been receiving a lot of press in recent years, for current and future clinicians, what are some important take away points you could share?
Societal awareness of concussion and of the longterm sequelae of repeated concussions, including CTE, has been an important step forward. There is much more we need to learn about CTE and we will do so through research as we are better able to correlate clinical findings with brain biopsy studies. The takeaway points for now are that we should (1) prevent concussions whenever possible through safety measures (protective helmets, changes in sports rules, etc) and (2) make sure patients are fully symptom-free from one concussion before resuming activity that could put them at risk for another.
I have found that many students are surprised to see the level of recovery some TBI patients experience following an inpatient rehabilitation stay, do you have any experiences that stand out in your mind over the course of your career?
We cannot always predict how patients will recover, but I am always amazed and gratified when patients make a dramatic recovery after TBI. Not long ago we treated a young man who sustained a severe TBI from an all-terrain vehicle accident. He was initially assessed to be at too low of a functional level even to undergo inpatient rehabilitation. Within a few days he woke up in the acute care hospital, went through our inpatient rehabilitation, and left essentially independent.
Another patient had a severe TBI from a motor vehicle crash and was admitted in a very confused and agitated state. She made excellent progress both as an inpatient and afterward. It has been a few years since her injury and she is now in France teaching at one of the most prestigious universities in the world.
PM&R continues to grow, what goals do you have for the specialty? Is there a particular direction you hope this specialty takes in the years ahead, or a role that you think it could serve particularly well in the 21st century healthcare system?
I see a lot of exciting opportunities for the field of PM&R. The shift to value-based reimbursement in healthcare will give PM&R an opportunity to demonstrate that rehabilitation can lead to better outcomes. Evidence-based research studies in this area become even more vital. PM&R’s mission to preserve function and quality of life fits beautifully with the needs of the growing older population. Because of advances in trauma and surgical care we now save patients who would not have survived before, which makes rehabilitation all the more important.
What parting advice would you give medical students who are thinking about or currently pursuing PM&R as a career? How about specific advice for other healthcare professionals?
Realize that PM&R is a very broad field, and try to get exposure to its different aspects to see if it is right for you. For example, outpatient back pain and inpatient spinal cord injury are two very different areas within the speciality.
Healthcare providers have hard work, stress and long hours. Exercise and meditation are two practices that are essential to stay physically healthy and mentally balanced, in my opinion.
You will be just as busy after medical training as during training, so the time to start making these practices a habit is today; even a little bit works wonders.
PM&R physicians have to motivate others and we can set the example by being physically fit, positive-minded and cheerful. Think of your duties in healthcare as “service” rather than “work.” With this simple idea you will automatically do an excellent job and be full of energy and enthusiasm.
Lauren Chambers, DO, is a PGY4 Physiatry Resident at Carolinas Rehabilitation in Charlotte, NC. She will be entering a Sport and Spine Fellowship at OSS Health in York, PA.
Interviewed by Brandon Barndt, OMS-4
A little bio: where are you at in your career? What is your current position? Any organizational involvement, PM&R or otherwise? Anything else that is unique about you that would be good for readers to know, such as passions within PM&R?
I am a PGY4 resident at Carolinas Rehabilitation and the Resident Council President for the American Osteopathic College of Physical Medicine and Rehabilitation (AOCPMR). After residency I will matriculate into a sport and spine fellowship at OSS Health in York, PA. The most fulfilling aspect of my day involves finding ways to restore function and improve patients’ quality of life. I plan on practicing outpatient musculoskeletal medicine and interventional physiatry to help my patients maintain their desired lifestyle.
I am interested in incorporating the use of MSK and nerve US, interventional techniques, regenerative medicine, and integrative medicine into my practice. I have a special interest in outcome monitoring and the diagnosis and treatment of brachial plexopathies and peripheral nerve injuries.
As we introduce more medical students, physicians and healthcare professionals to Physical Medicine and Rehabilitation (PM&R)—also known as physiatry—could you tell us how you became interested in the field?
My path to PM&R began in high school while volunteering at a school for children with significant handicaps and special needs. The teachers and therapists had an enviable ability to instill peace and hope to a challenged group of children and their families. Witnessing the teamwork displayed in providing complex medical care inspired me to consider a career working with this population. I had the good fortune to shadow a pediatric physiatrist after my college advisor introduced me to the specialty of PMR. This experience allowed me to witness firsthand how the specialty of PMR could positively impact a patient’s quality of life, and I immediately began pursuing a career in this field.
During residency I discovered that my professional and personal and experiences influenced my interests and shaped my future goals. Throughout my medical training I found the most fulfilling aspect of my day involves finding ways to restore function and improve patients’ quality of life. As a former competitive soccer player, personal trainer, and someone still active in fitness, I have a personal passion for optimizing health. My experience recovering from 2 ACL injuries gave me insight into the psychosocial aspects associated with a loss in function and the process of rehabilitation. Musculoskeletal medicine became the specific area of PMR with which I most identified.
As the President of the AOCPMR Resident Council, how has your experience been in your position?
I first joined the AOCPMR in 2010 and have served in various leadership positions at both the local chapter and national levels, culminating in my current position as resident council president. I have always enjoyed my experiences with the AOCPMR. Initially I was attracted to the organization’s strong spirit of camaraderie and I appreciated that despite being a first-year medical student, my presence was welcome and valued by the organization. However, it is due to the unique resources devoted to student and resident education that I have been able to participate in numerous opportunities that have supplemented my formal medical training and furthered my professional development. In my current role as president, I most enjoy facilitating the implementation of our members’ visions as they are dedicated to improving the student and resident experience through the development of new resources.
Why do you recommend medical students and residents get involved with organizations like the AOCPMR?
Joining a professional organization allows one to stay informed about advances in medical knowledge and changing healthcare policy, participate in advocacy for the procession, and to network and meet others with similar interests. Involvement can also aid in career fulfillment. Pursuing leadership opportunities within your professional organization is a great way to further develop your professional skills while also giving back.
Whether you are looking for mentorship, academic, professional or personal growth opportunities you will find a home at AOCPMR regardless of your allopathic or osteopathic background. Most importantly you should select an organization that inspires you and aligns with your personal interests.
What advice would you give medical students interested in the field? Are there particular experiences that you would suggest they seek out during their medical education?
PM&R is a broad field of practice and during medical training it is important to develop a solid foundation in human anatomy and internal medicine. There are several opportunities for specialty board certification, and the number of sub-specialties in which a physiatrist can focus further expands if you include those areas that do not currently have an option for formal board certification. See below for a list of examples.
Examples of Board Certifications:
-TBI, SCI, Hospice & Palliative Care, Neuromuscular, Pediatrics, Pain, Sports
Examples of other areas for sub-specialization:
-Stroke, Cancer, Cardiopulmonary Rehabilitation, Subacute care, Musculoskeletal, Occupational medicine, Prosthetics & Orthotics, Electrodiagnosis, Wound care
During your PM&R rotations, seeking exposure to both inpatient and outpatient practices will help you broaden your insight into what the field of PM&R offers. Students may find electives in neurology, radiology, geriatrics, urology, orthopedic surgery and neurosurgery helpful in preparation for a career in PM&R.
From your experience, what are the qualities of an excellent Physiatrist (PM&R physician)?
The excellent physiatrist provides sound medical management and acknowledges the biopsychosocial needs of the patient. It is important to be a physician leader who works as part of a team to provide compassionate, patient-centered care. Rehabilitation patients have multi-disciplinary needs, and a wise physiatrist is knowledgeable of their community resources and able to practice appropriate systems-based care. Formal monitoring of patient outcomes in response to the care delivered provides invaluable feedback to both the patient and practitioner. Utilization of a practice style that affords the provider the ability to monitor outcomes will provide them with an edge in clinical decision making and durability in a changing healthcare system. Lastly, though not specific to physiatry, curiosity and a commitment to continued education are characteristics of quality a physician.
7) As physiatry continues to grow and becomes more integral to the nature of the 21st century healthcare system, do you see any future changes or would you advocate for any? What goals do you have for the specialty?
In 2016, the American Heart Association and American Stroke Association released the first ever stroke rehabilitation guidelines which state that rehabilitation should take place at an inpatient rehabilitation facility rather than a nursing home due to the ability for rehabilitation to improve patient outcomes. The ability for rehabilitation to improve outcomes is increasingly gaining recognition and I anticipate continued recognition of the value provided by physiatry services for an expanding number of medical conditions.
The ability to deliver value-based care and demonstrate quality of care to both patients and third parties are topics of national conversation. Monitoring patient outcomes can be used to assess whether value-based, quality care is being delivered while also providing information that can be useful for conversations between patients and providers to help direct patient care. As physiatrists, we should be leaders in the development and utilization of outcome measures to monitor patient response to treatment, facilitate conversations with third party payers and assess quality.
Matt Smith, MD (July 20, 1979 - September 19, 2016) was Board certified in Physical Medicine and Rehabilitation with fellowship training and further board certification in Pain Medicine and interventional pain procedures. He was part of Alabama Pain Physicians, and practiced Pain Medicine, Wellness, and Performance Medicine in Birmingham, Alabama, where he lived with his wife, Meggan. In addition to his medical practice, Dr. Smith's professional interests included teaching at the University of Alabama, Birmingham, research, and the quantified self movement. He was also fond of strength training, cooking, walking around local trails, and paddleboarding. Some of his writing can be found on his website, Barbells and Stem Cells (www.docmattsmith.com).
Originally Interviewed by Dr. Jim Eubanks in February, 2016
How did you become interested in medicine, and specifically, what attracted you to the field of Physical Medicine and Rehabilitation (PM&R)?
First, regarding Medicine: I, like most physicians, felt an affinity for the practice of medicine since childhood. Ever since I realized that at some point I would have to get a job – probably sometime around age four or five – I thought that being a physician seemed like a great thing to be.
At the age of 19, I also had the special privilege of having a rare type of adolescent soft tissue cancer called a Ewing’s Sarcoma. I went through the whole gamut of radiation, chemotherapy, surgery, more radiation and chemotherapy, and all that. Plus, after treatment, I was able to experience a whole host of complications that are frequently only relegated to our patients, including relapse with metastasis later on. Prior to this experience, I had always had the vague ambition to get in as good of “shape” as I could. I played sports in high school and was fair to mediocre, but I never had a systematic plan of focusing on trying to make myself as good physically as I could. Once I had my health really taken away, my resolve to rebuild myself in spite of my newfound challenges was increased. This lead to an interest in the idea of rehabilitation, and, by extension, physical medicine.
While in med school, I was also fascinated by neurology. This was preceded by one of my mentors in college, who was one of my thesis advisors, and a great neuroscientist. So, I had this personal interest in rehabilitation that stemmed from my own challenges, and an academic interest in neurology. I would also come to really become personally interested in the phenomenon of pain, nutrition, and psychology, and how all of these are related. As far as how this translated into my interest in PM&R, to be honest, I did not even know what PM&R was until halfway through medical school. However, I had the privilege to have Dr. James Atchison (currently at RIC), as a guiding force and another mentor during my last year and a half at UF. I came to realize that PM&R fit nearly perfectly all of my interests. Anyone who is currently training to become a physiatrist or who is one already should hopefully easily see why.
Could you tell us about your work in interventional spine care, and what kinds of medical problems and conditions you address in your practice?
After my residency, I trained with Brad Goodman, MD and Srinivas Mallempatti, MD in interventional spine procedures in Birmingham, Alabama. I learned a tremendous amount with them and still do, in fact, as we still keep in touch and try to work together on a few things. After my fellowship, my first position at a practice of my own was with Chetan Patel, MD, a renown orthopedic spine surgeon and at that time chair of robotics for the North American Spine Society (NASS). He was also a great influence on me and helped me round out my understanding of total spine care. I also had the fortune to become good friends with a number of my colleagues who are physical therapists with further training in spine care. All of these influences, plus my own growing clinical experience, helped me to develop my current philosophy of spine care and (hopefully) ever-growing knowledge base and skill set.
As you may know, one of my main interests in spine care, and pain medicine in general, is how it is related to the phenomenon of the “metabolic syndrome”. The metabolic syndrome has classically been thought to be a constellation of somewhat related pathologies including glucose dysregulation, hypertension, central obesity, hypercholesterolemia, and whatnot. Well, it appears that one of the strongest correlations of spine pain and spondylosis, or degeneration of the spine, is the metabolic syndrome. In fact, one of our patients is more likely to have back pain with the metabolic syndrome than they are with bad MRI findings. Thus, for all of one’s knowledge of spine anatomy, if a physician does not understand the metabolic syndrome, then they don’t really understand back pain. What’s even more interesting is how other phenomena: anxiety disorder, sex hormone abnormalities, chronic opioid use, and even traumatic brain injury, also seem to be related to the metabolic syndrome. As I see patients with all of these now, it has been exciting to dig into some of the underlying, deeper pathology that seems to be linking what was heretofore thought to be unrelated pathologies.
To try and answer your question more directly, the kinds of medical problems and conditions that I address in my practice are somewhat wide-ranging. The brief answer is that, by and large, I treat pain of all stripes. Everything from pain from chronic pancreatitis to acute disk herniation, to fibromyalgia, to systemic lupus erythematosis, to various neuropathies. However, as I am also interested in the underlying physiology relating the metabolic syndrome and systemic inflammation to all sorts of chronic pain, we have developed a practice model that also focuses on treating other pathologies, or maladaptations, such as obesity, physical deconditioning, and various psychological disorders that are now known to be part of the many-headed Hydra that is the metabolic syndrome.
It is because I subscribe to this multimodal approach with a rehabilitation-first and systems based approach that I consider myself a Pain Physician only by way of Physical Medicine and Rehabilitation.
Thanks to data collected by the Global Burden of Disease 2010 Study, we now know that spine-related disorders are the #1 cause of disability worldwide. From your perspective, what are some of the most important issues we face as we attempt to tackle this growing public health issue? Do you have specific goals or hopes for spine care in the years ahead?
The number one thing to do is to stop smoking. There is incontrovertible evidence that this leads to microvascular changes leading to spondylosis and likely other degenerative changes.
Next is to address obesity. Obesity of course leads to mechanical disadvantages but, what is likely more important, it causes a body-wide proinflammatory milieu via the effects of visceral adipose tissue and various “adipokinins”. This, of course, is one of the reasons why spondylosis and back pain are related to the metabolic syndrome.
From a public health perspective, therefore, much more effort needs to be placed emphasizing the need for a good diet and regular exercise: including low level aerobic activity, mobility work, and – gasp! – strength training. Not to sound jaded, but ask your average physician how to do a squat. A real squat: glutes to haunches. Now, ask him or her not just how to do one (if they know how) but to do one themselves. Ask around. See how many can. Then see if you yourself can. You will likely be disappointed all around.
Now, go to nearly any developing country that has not yet adopted the typical developed world’s diet and lifestyle. Find the oldest individual that you can who is not near death. Ask him or her how to do a squat. Your chances are far greater that this individual will be able to show you how to do it better than your average medical student or attending physician. Also, measure their BMI and possibly their lean body mass. This may also be better than the average physician.
So, regarding public health, step one is to change this. Most physicians don’t practice what they preach. Until this changes, we shouldn’t worry about public policy because it likely will not do any good. Before we can change the world we need to change ourselves.
Regarding interventions, the most exciting stuff is of course the so-called “regenerative medicine”. Now, while injecting stem cells into disks is awesome and will likely improve in sophistication and efficacy in the years to come – and I am currently engaged in trying to bring this to fruition – we should not forget that we already have a tremendous amount of stem cells already. Kirkaldy-Willis and others since have shown that the spine can heal on its own. We also now have human models that show that smart exercise can expedite this. And we know from murine and other models that stem cells in the disk can also regenerate and lead to histological improvements that are spurred on solely by the right kind of exercise. Thus, while we will hopefully have ever better procedures in the years to come, I am still very bullish on our increased sophistication with old school physical medicine and rehabilitation.
In addition to your background as a philosophy major, you recently started a blog, Barbells and Stem Cells, which explores game-changing therapies like stem cells, new medications, and lifestyle changes. How do you incorporate your diverse interest in the clinic and as a physician in general?
Well, I touched on some of this in the earlier questions. To say it in a different way and perhaps elucidate on why I chose that name for my site (besides the fact that it rhymes and I thought it sounded cool) was because the needle that injects stem cells and the barbell are more related than many know. Progressive overload with a barbell or other means causes the “eustress” or good stress or “hormesis” that elicits our own cells to adapt to this stress. It is this same type of hormesis that lets us now grow cortical grey matter via constraint-induced therapy in patients with a stroke. It is this hormesis that precipitates better bone density improvements in osteoporosis with strength training than any bisphosphonate. And there are numerous other examples of how well-applied stress leads to better therapies than most pharmaceuticals or procedural interventions.
So, if my chief interest in regard to pathology is how the metabolic syndrome is related to the diseases seen with PM&R, my chief interest in regard to treatment is the smart use of hormesis.
PM&R continues to grow, what goals do you have for the specialty? Is there a particular direction you hope this specialty takes in the years ahead, or a role that you think it could serve particularly well in the 21st century healthcare system?
I would like to see the average physiatrist become well versed and skilled in the application of both barbells and stem cells, both professionally and personally.
I would love to see every AAPM&R annual meeting have a workshop showing physicians how to do a correct back squat, front squat, and deadlift.
I would love to see more cross-pollination between physiatrists, internists, and endocrinologists exploring how they are oftentimes treating manifestations of the same underlying pathology (the metabolic syndrome).
And of course, I would also like to see more advances in the procedural aspects of pain medicine. I would love to see in my lifetime a combination of smart procedures and smart uses of hormesis abolishing the need for opioids.
As for PM&R’s role in the 21st century, I think that it is going to be massive, if we focus on things such as the proper application of things old and new – things like barbells and stem cells. If I had to start over and pick a field to go into right now, I would choose exactly what I did. There is a reason PM&R is gaining in popularity. Our field is something of a hybrid of several other fields. Because of this, I believe that we are experiencing some hybrid vigor. If we follow this trend, I think that our field will be considered the vanguard of the most impactful revolutions in medicine.
What parting advice would you give medical students who are thinking about or currently pursuing PM&R as a career? How about specific advice for other healthcare professionals?
If you are pursuing a career in PM&R, I would simply say, “good luck!” I think that you have chosen wisely. I love this field and I hope that you do, too.
To somewhat diverge from my previous ramblings, I’ll give some other advice:
Be very, very good with money. Don’t spend it on stuff you don’t need. And you likely need much less than you think you do. Further, except for a few of you, while you are probably spending more money than your should on frivolities, you are also probably not buying what you actually do need. This includes healthy, tasty food that you cook yourself in a cast iron skillet and a squat rack. Change this.
With all of my health problems and other struggles, I have learned that the things that provide happiness frequently have little to do with money. Therefore, I try to not spend money on stuff that is not only expensive, but distracting. The Nobel Prize winning psychologist Dan Kahneman (and his deceased partner Amos Tversky) have shown that the average American household gets no more happiness in relation to money after they make more than $75,000 per year. You need to make sure that you can afford health insurance, rice and beans, and enough clothes to go to work and for walks outside. Other than that, the only things that have been shown to consistently lead to happiness are a sense of autonomy, mastery, and purpose. Focus on the latter.
In this vein, in addition to being good with money, you need to find a mentor. If you are a medical student, resident, fellow, or just starting out in your practice, find people who know more about something than you do and incessantly (and politely) learn everything that you can from them. Do this all the time, hopefully for the rest of your life. And when you have started to master something, find your own apprentices.
And, as the master of mastery, Robert Greene, has said: while you should always seek to learn from others, once you reach a certain point, you should be willing to break out of the purely master/apprentice system. I personally love private practice for just this reason. I learn stuff every day from my colleagues and friends. But I am responsible for myself and can safely say that I have autonomy, some mastery, and certainly purpose.
Furthermore, while my health is far from perfect, this is more than made up for by the fact that I have a loving wife and family. I hang out with them, deadlift, squat, press, do pull ups, walk, and read constantly. These are the things that make me happy and I have them in spades. I do not think that I am alone. Things like these are probably what makes most people happy. Humans really aren’t all that different on a fundamental level. If tomorrow my CPT reimbursements get cut horribly, while I wouldn’t be thrilled, it certainly would not fundamentally impact my life. On the contrary, if I couldn’t hang out with my wife or enjoy a book or the outdoors, I would be much worse off.
In short, if you can manage to have a good family life, enjoy sitting still, walking slowly, and lifting weights; if you can save most of your money and have purpose, mastery, and autonomy, you have a really good chance of being happy. And this will also likely make you better at your job. Happy doctors tend to be better doctors, in my experience.
Matt Smith, MD
Elliot J. Roth, MD is the Paul B. Magnuson Professor and Chairman of the Department of Physical Medicine & Rehabilitation at Northwestern University Feinberg School of Medicine, Chairman of the Department of Rehabilitation Medicine at Northwestern Memorial Hospital, and Co-Medical Director of the Brain Innovation Center at the Shirley Ryan AbilityLab (formerly the Rehabilitation Institute of Chicago, or RIC).
Originally Interviewed by Dr. Jim Eubanks in January, 2016
How did you become interested in physical medicine & rehabilitation (PM&R)?
When I entered medical school at Northwestern, I had never heard of the specialty. But during medical school, I spent time at the Rehabilitation Institute of Chicago (RIC) and enjoyed the interactions with patients who were in great need, the opportunity for long-term relationships with patients, recognition of the importance of holistic care including mental health and social issues, the intellectual stimulation of the problems with which the patients presented, the many research questions raised by these patients’ problems, and the opportunity to collaborate with strong clinical teams.
PM&R’s focus on the functional recovery of patients interests many providers. One of your areas of specialization is patients affected by stroke. Could you tell us a bit about your work in stroke treatment and management as a PM&R physician?
Stroke rehabilitation is a truly holistic and interdisciplinary specialty, involving the application of interesting physical and functional interventions, but also addressing psychological and social issues, including motivation level, mood, social support systems, and other aspects of care. As PM&R physicians, we evaluate the patients, oversee and often directly apply these interventions to address their issues. An important role is to communicate with patients, families, referring physicians, and future care providers. People with stroke often have a number of associated medical conditions as well that require physician evaluation and management.
As PM&R continues to grow, what goals do you have for the specialty? Is there a particular direction you hope this specialty takes in the years ahead, or a role that you think it could serve particularly well in the 21st century healthcare system?
An important role for PM&R specialists is to integrate into the care teams of other specialists and care providers, in order to provide comprehensive and appropriate care for people with a variety of disabling conditions.
An exciting development at the Rehabilitation Institute of Chicago (RIC) is the 2017 opening of its new, state-of-the-art research hospital, the Shirley Ryan AbilityLab (SRAlab). With a focus shifting towards greater collaboration between physicians and allied health providers, researchers, patients, and families, what would you like to share with us about the work that will take place at SRAlab?
A central theme of the new building is the closer integration of patient care and research, built into the new structure. This will better enable clinicians and investigators to “rub elbows” with each other, maximizing both the convenience of organized interactions and the likelihood of chance meetings to facilitate more collaboration. This will inform, enrich, make more relevant, and make more compelling, the research activity. It also will enhance the clinical care by making it more “cutting edge,” innovative, and this will all be conducted with a “sense of inquiry.” Another important theme is the heavy focus on the use of rehabilitation practices that are based on scientific evidence.
As the Paul B. Magnuson Professor and chairman of the Department of PM&R at Northwestern University Feinberg School of Medicine, as well as Attending Physician and Medical Director of the Patient Recovery Unit at RIC, what advice would you give medical students who are thinking about or currently pursuing PM&R as a career?
PM&R is an ideal specialty for physicians who are interested in holistic comprehensive care, who like to collaborate with others, and who enjoy their interactions with patients and their families. It is valuable to spend time with PM&R physicians and patients during medical school to get a feel for the role and the unique experiences of the people in the specialty.