|CHAPTER 7: THE ORGANIZATIONS OF PHYSICAL AND REHABILITATION MEDICINE IN THE WORLD
|Year : 2019 | Volume
| Issue : 2 | Page : 139-142
7.3 The organizations of physical and rehabilitation medicine in the world: Physical and rehabilitation medicine in the Americas
Alberto Esquenazi1, Walter Frontera2
1 Department of Physical Medicine and Rehabilitation, MossRehab/Einstein, Elkins Park, PA, USA
2 Department of Physical Medicine, Rehabilitation and Sports Medicine, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
|Date of Web Publication||11-Jun-2019|
Prof. Alberto Esquenazi
Department of Physical Medicine and Rehabilitation, MossRehab/Einstein, Elkins Park, PA
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Esquenazi A, Frontera W. 7.3 The organizations of physical and rehabilitation medicine in the world: Physical and rehabilitation medicine in the Americas. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:139-42
|How to cite this URL:|
Esquenazi A, Frontera W. 7.3 The organizations of physical and rehabilitation medicine in the world: Physical and rehabilitation medicine in the Americas. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:139-42. Available from: http://www.jisprm.org/text.asp?2019/2/2/139/259358
| Introduction|| |
In North America, there is very good representation for the field of physical and rehabilitation medicine (PRM). The three countries of the region have specialized physicians in the field. The criteria for specialization vary widely, and certification is not universally implemented or required. The specialty in the USA is relatively young. On February 27, 1947, the American Board of Physical Medicine was incorporated and recognized by the American Board of Medical Societies and the American Medical Association. Dr. Frank Krusen was named its first chairman.
The US has the largest contingency of physiatrist for the American continent, their scope of practice is defined as follows: “physiatrists specialize in the evaluation, diagnosis and treatment of patients of all ages with functional impairments, painful conditions and/or cognitive impairments related to the central and peripheral nervous system, cardiopulmonary and musculoskeletal systems. Patients diagnosed and treated by physiatrists may have orthopedic, neurologic, rheumatologic, oncologic, vascular, industrial/occupational, cardiovascular, pulmonary, or sports-related conditions.”
Physiatrists may perform: “Neurophysiologic and electrodiagnostic studies, musculoskeletal sonography, fiber optic endoscopic evaluation of swallowing, interventional pain treatment, joint injections, percutaneous spinal cord stimulation/implantation, intrathecal pump trial, placement and management, radiofrequency ablation, Interventional treatment for spasticity, anesthetic, neurolytic, chemodenervation and therapeutic injections, manipulation/mobilization, acupuncture and dry needling, hyperbaric oxygen treatments and other forms of treatment.”
Currently, in the US, there are about 11,800 trained PMR specialists, with nearly 9000 who are board-certified practitioners. Approximately 69% work in physical medicine, the rest focus in rehabilitation with 2500 physiatrists in academic practices distributed among 80 PMR departments.
In the USA, there are 88 residency training programs with approximately 1000 residents in training in a 4-year program and 50 fellowship training positions for pediatrics, spinal cord, pain, palliative care, brain injury medicine, and sports medicine. JAMA, September 2017.
The US counts with 1180 rehabilitation hospitals and units with 40,000 licensed beds. The total Medicare expenditure for inpatient rehabilitation care in 2016 was $6.32 billion (equivalent to 6.3% of the total health-care costs) with 360,000 inpatient admissions in 2014. The average per case payment was $15,205 with an average length of stay of 15.1 days Report to the Congress: Medicare Payment Policy, March 2016. Neurological and orthopedic rehabilitation were the largest diagnostic groups served.
Three organizations represent the specialty of PMR physicians, also known as physiatrists. The American Board of PMR certifies training to uphold the recognition of specialization. The American Academy of Physical Medicine and Rehabilitation (AAPMR) is the national medical specialty organization representing physicians who are specialists in physical medicine and rehabilitation with nearly 9000 members and founded 80 years ago. The Association of Academic Physiatrist with approximately 1100 members has a singular focus in academic endeavors. Individuals may be part of multiple organizations based on their interest and area of focus.
Canada, a country with a population of nearly 40 million, has about 500 physiatrists, while Mexico with a population of 128 million has about twice of that number, indicating a comparative limitation in availability of service providers. The Canadian Association of PMR is now 40 years old; 42% of its members practice in a private setting and there are nearly 140 residents in training in a 4-year program.
In 1965, the Mexican Institute of Social Security opens its first postgraduate training program in rehabilitation. The current PMR training programs throughout Mexico graduate 75 physiatrists every year.
In Mexico, there are two major organizations that represent physiatrist: The Mexican Society of Physical Medicine and Rehabilitation and the Mexican Board of Rehabilitation Medicine.
The Mexican Society of Physical Medicine and Rehabilitation was founded 43 years ago with the goal of academic and scientific development of the specialty and its members. The Mexican Board of Physical Medicine and Rehabilitation is in charge of Certification and Re-Certification of specialists in PMR. Currently, there are more than 1300 practicing PMR physician in Mexico. Not every physiatrist has to be certified or recognized by the accrediting board (Academia Mexicana de Medicina Fisica y Rehabilitacion).
In the US, board certification requires completion of a 4-year accredited residency training program and passing of a written and an oral examination after 1 year of practice. Most subspecialization training requires an additional year of training, followed by a written examination. Currently, it is required to recertify every 10 years in general PMR or a subspecialty.
In Canada, board certification requires completion of a 4-year residency training program and passing of a written examination.
In Mexico, board certification requires completion of a 3-year residency training program, development of a thesis and presentation of the material in front of an examination panel.
There are multiple publications relevant to PMR in the region. In the US, there are three journals for the field. The American Journal of PMR (managed by AAP), PMR the Journal of Injury, function, and Rehabilitation (managed by AAPMR) with the largest reader number and the Archives of PMR (managed by the American Congress of Rehabilitation). The first 2 journals publish their abstracts in English and Spanish. The Archives of PMR is the oldest of the three journals. Several other journals that are topic specific are also published in the US. The Mexican Society publishes a quarterly journal in Spanish. The Canadian Society publishes the Canadian Journal of PMR.
In the US, there are two educational meetings every year focused on physiatrists. The annual meeting of AAPMR is the largest and takes place during the Fall. This meeting has different tracks that provide clinical-focused learning opportunities in most areas of PMR. The meeting attracts several thousand physiatrists and has a large exhibit hall with technology- and rehabilitation-related products. There are multiple hands-on courses, lectures, and keynote presentations. During the Spring, the AAP holds its meeting with a focus on academic topics and development of teaching skills in clinical topics. This is the meeting for those in need of information related to PMR departmental structure, career development, residency training, and research activities.
The Mexican Society holds a meeting every year which attracts physiatrist, therapists, and technical staff with a clinical focus. The Canadian Society also holds an annual meeting for its members, which combines clinical and academic information.
The three countries have different health-care structure and varied finance systems. Canada has a universal health system that is government sponsored and supplemented by private insurance. The system is financed and administered at the provincial level and care reimbursement varies based on location. While in Mexico, the system of health care has four financial arms. The largest is the Social Security System of health care with its own hospitals, clinics, and employed doctors. The system extends to their dependents and is funded by employer's tax and supplemented by worker's tax. Governmental employees have a parallel system of care that is funded by the government, and there is a public health-care program for uninsured persons. There is a private health-care system that relies on private insurance and self-pay for those that can afford it.
Although the current public health-care policy of Mexico is focused on the development of “close to home” rehabilitation centers, there is a large concentration of services in the metropolitan areas of the country. This is why the governmental institutions are developing programs to bring services close to the homes of those individuals in need of rehabilitation care (Guzman JM. PMR 2012 PMR Volume4, Issue10 October 2012 Pages 770-772 http://dx.doi.org/10.1016/j.pmrj.2012.09.577).
The most complex and likely least efficient of the systems is the one available in the US which has high administrative costs. It has a Social Security System (Medicare) which is funded through an employer/employee tax accumulation program that covers everyone over age 65 and those with disabilities lasting more than 2 years. Although administered by the government, care is provided in the private health-care sector. The underinsured or uninsured are covered by the individual states with support from the federal government. There is an employer-/employee-sponsored insurance skim, which varies by employer in cost and coverage with a minimum threshold requirement. The veterans and active duty military have the largest health-care system and one of the largest in the world with its own health-care infrastructure, hospitals, clinics, employed physicians, and unique electronic medical record that covers all of the country and military bases in areas worldwide. An individual private insurance market covers many people, and currently, there are about 12 million people in the US without health insurance.
There are collaborative agreements for membership, knowledge sharing, education, and care resources across the US and Mexico through the Academy of PMR and the Mexican Society of PMR; this collaboration started nearly 5 years ago and is perceived as successful for both organizations. Other collaboration and membership agreements exist between the American Academy of PMR, the AAP, and the International Society of PRM (ISPRM).
In all three countries, PMR services span from acute care through all levels of postacute care. A large private practice base exists for physical medicine in all three countries, but a multidisciplinary team approach to care is prevalent for all venues particularly in rehabilitation.
There are opportunities to learn from these different systems of care and their varied financial structure. Increasing collaboration in education, clinical, and administrative areas and cross-border research would benefit all. ISPRM is developing opportunities for this to happen and I hope we all take advantage of them since the region is physically and economically interconnected and opportunities are abundant.
The North America region is composed of three countries: Mexico, US, and Canada. Together, they hold a very large physiatric contingency that is well represented across the inpatient, outpatient, and other levels of care. Private practice, academia, and governmental employment are distributed in all countries.
The three countries have strong residency training programs and publications. Research is stronger in USA and Canada with good opportunity to develop in Mexico.
The region is increasing its collaboration in academia and research, and there is a strengthening link between the three countries that support ISPRM.
| Latin America|| |
Latin American Medical Association of Rehabilitation
The growth and development of PRM in Latin America is reflected in the organization of the Latin American Medical Association of Rehabilitation (AMLAR). AMLAR was organized in August 1961 on the occasion of the first Mexican Congress of Rehabilitation. It is important to note that, although Mexico is considered to be part of North America from a geographical point of view (see section above), it has been a pioneer in the development of AMLAR which includes all countries in Central America, South America, and some countries in the Caribbean regions.
The beginning of PRM in Latin America was associated with the development of clinical services for patients with poliomyelitis because, at the time, it was a frequent cause of disability in the region. It was thus important to harmonize criteria for the education of PRM specialists and the standardization of clinical services. During the first meeting of AMLAR, representatives from 13 countries participated in the discussions.
In 2019, a total of 24 countries are official members of AMLAR (https://www.portalamlar.org). AMLAR has organized 28 Regional Congresses since 1963. The first Congress was held in Mexico City and the most recent one in Ecuador (2018). Currently, this is a biannual event. Three subregional organizations exist within AMLAR including the following: (1) Medical Association of Rehabilitation of the Antilles; (2) Medical Association of Rehabilitation of the Andes (including Bolivia, Colombia, Ecuador, Panama, Peru, and Venezuela); and (3) Medical Association of Rehabilitation of Central America and the Caribbean. Three scientific journals are officially listed by AMLAR including (1) American Journal of Physical Medicine and Rehabilitation (AJPMR); (2) Colombian Journal of Physical Medicine and Rehabilitation; and (3) Cuban Journal of Physical Medicine and Rehabilitation. AMLAR has established an official relation with the AAP in the US that includes the AJPMR. The development of educational programs in PRM in different countries in Latin America is discussed in Chapter 4.2.
Rehabilitation in the Americas: A Report of the Pan American Health Organization
The situation of rehabilitation in the Americas has been recently summarized by Antony Duttine, Advisor on Disability and Rehabilitation for the Pan American Health Organization (PAHO), the regional arm of the World Health Organization (WHO) for the Americas (https://www.paho.org/). The organization of PRM in Latin America responds to the needs and action plan identified and recommended by PAHO. Like in other parts of the world, rehabilitation services in Latin America and the Caribbean have been evolving due to the increase in the prevalence of noncommunicable diseases, the aging of the population, and the increase in the number of years lived with disability. PAHO has included rehabilitation as part of the organization's Strategic Plan. However, there is wide variation in the nature and scope of rehabilitation services in the region, and many countries do not have a national action plan with or without PRM. One notable exception is the State of Sao Paulo, Brazil, where the government has established a Secretariat for the Rights of Persons with Disabilities with extensive PRM services. PRM services are included at different levels, including, in few countries, the community level. Speech therapy and hearing services have been developed in Guyana, Honduras, Paraguay, and El Salvador in collaboration with the American Speech-Language-Hearing Association. PAHO has established collaborating centers in Mexico and Brazil, both with extensive PRM presence. In some countries, rehabilitation services including PRM specialists are housed in ministries other than the Health Ministry (for example, Social Welfare).
Areas of particular interest in clinical physical and rehabilitation medicine services
According to the World Report on Disability published by the World Health Organization and the World Bank in 2011 (see full report: www.who.int/disabilities/world_report/2011/en/), approximately 6.2% of the population in the 24 countries members of AMLAR live with a disability (range from 1.5 to 14.9). As a consequence, the mean years lost to disability in this group of countries is 9.4 years (ranged from 7.9 to 11.7). The noted variability among countries may be real but may also reflect differences in statistical reporting and data collection systems.
Some areas within the field of PRM have developed at a faster rate and have a stronger clinical base in Latin America. For example, The Latin American Society of Paraplegia (SLAP) was established in 1994 in Brazil and includes members from various countries. The SLAP organizes meetings regularly, sometimes, in coordination with the AMLAR Congress. Another area of interest has been prosthetics and orthotics (PO). A special committee of PO is part of the organizational structure of AMLAR with participation in the International Society of PO. A third area of special interest within AMLAR is electrodiagnosis with very well-developed clinics in several countries, including, but not limited to, Brazil, Colombia, Honduras, Mexico, and Uruguay. A chapter of the International Federation of Clinical Neurophysiology has been established in Latin America.
| Conclusion|| |
The North America Region is composed by three countries: Mexico, US, and Canada. Together, they hold a very large physiatric contingent that is well represented across the inpatient, outpatient, and other levels of care. Private practice, academia, and governmental employment are distributed in all countries.
The three countries have strong residency training programs and publications. Research is stronger in USA and Canada with good opportunity to develop in Mexico. The region is increasing its collaboration in academia and research, and there is a strengthening link between the three countries that support ISPRM.
Latin American countries (24) work together in AMLAR representing Central America, South America, and the Caribbean. Significant variability exists among countries regarding the development of the specialty of PRM and the provision of rehabilitation services. Many of the action plans are guided by the Pan American Health Organization and respond to the WHO Rehabilitation 2030: a call for action. Some of the clinical areas that are part of the specialty of PRM have developed faster in Latin America.
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Conflicts of interest
There are no conflicts of interest.