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 Table of Contents  
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 58-64

4.2 The education of the specialist of physical and rehabilitation medicine: Graduate medical education in residency training

1 Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, New Jersey; Department of Neurosurgery and Physical Medicine and Rehabilitation, New Mexico School of Medicine, Albuquerque, New Mexico; Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Pullman, Washington, USA
2 Sunnybrook Health Sciences Centre, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
3 Mexican Society of Physical Medicine and Rehabilitation, Mexican Academy of Surgery, Mexico City, Mexico
4 Faculdade De Medicina FMUSP, Universidade De Sao Paulo, Sao Paulo, Brazil
5 Department of Experimental and Clinical Medicine, Politecnica Delle Marche University, Ancona, Italy
6 Department of Rehabilitation, Patras University Hospital, Rion, Greece
7 Department of Physiotherapy, Faculty of Health and Caring Professions, University of West Attica, Athens, Greece
8 Department of Rehabilitation Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
9 Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
10 Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
11 Chang Gung Memorial Hospital, Taiwan
12 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea

Date of Web Publication11-Jun-2019

Correspondence Address:
Joel A DeLisa
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DOI: 10.4103/jisprm.jisprm_15_19

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How to cite this article:
DeLisa JA, Berbrayer D, Guzman JM, Imamura M, Ceravolo MG, Barotsis N, Michail X, Haga N, Li J, Wang TG, Huang AM, Chung SG. 4.2 The education of the specialist of physical and rehabilitation medicine: Graduate medical education in residency training. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:58-64

How to cite this URL:
DeLisa JA, Berbrayer D, Guzman JM, Imamura M, Ceravolo MG, Barotsis N, Michail X, Haga N, Li J, Wang TG, Huang AM, Chung SG. 4.2 The education of the specialist of physical and rehabilitation medicine: Graduate medical education in residency training. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:58-64. Available from: http://www.jisprm.org/text.asp?2019/2/2/58/259341

  Introduction Top

Graduate medical education (GME) is, by definition, the career stage in which medical specialists in physical and rehabilitation medicine (PRM) are educated and trained. The curriculum for GME varies among countries of the world. The Education Commission of the International Society of Physical and Rehabilitation Medicine is working on developing a standardized curriculum and competencies that can be used all over the world.

This subchapter presents an overview of PRM physician training in selected countries from the following three regions as examples based on the availability of data: the Americas, Asia, and Europe. The length of training varies by country, with the shortest path being 3 years and the longest being 6 years.

  The Americas Top

United States of America – Joel A. DeLisa

PM&R (as the specialty is known in the United States) was approved by the American Board of Medical Specialties (ABMS) as a separate medical specialty board, American Board of Physical Medicine and Rehabilitation (ABPM and R) in 1947. The ABPMR has certified 12,155 physicians in PM and R, with 376 certified in 2016. There are currently 1325 trainees enrolled in 83 accredited PM and R residency programs. The residency training program, after graduating from an accredited medical school, consists of 4 years.[1] After successfully completing the residency training program, the physiatrist may choose to go into independent practice or complete a 1-year fellowship in one of the following seven approved subspecialties: brain injury medicine, hospice and palliative medicine, neuromuscular medicine, pain medicine, pediatric rehabilitation medicine, spinal cord injury medicine, or sports medicine. Fellowships in multisubspecialties can occur. As of now, 3991 diplomates have been accredited in one or more of these subspecialties.[1] All of these training programs must be approved by the Accreditation Council for Graduate Medical Education (ACGME) – PM and R Residency Review Committee.[2] This committee sets the training standards and evaluates and accredits each training program with respect to its facilities, didactic instructions, clinical experiences, electrodiagnostic consultations, therapeutic and diagnostic injections for spasticity management, as well as joint and soft-tissue management and pediatric rehabilitation. The 1st year of the residency is similar to a “rotating” internship. During the 2nd through 4th years of residency, the trainee must spend a minimum of 12 months but not more than 18 months, on inpatient experiences. Because patient medical acuity may vary, the expectations for an average daily census are eight patients, with a range of 6–14. The residents are expected to spend at least 12 months on outpatient and consultation services. It is expected that 50% of the faculty participate in the scholarship of discovery (as evidenced by peer-reviewed funding or by publishing original research in peer-reviewed journals), dissemination (as evidenced by peer-reviewed articles or chapters in textbooks), or application which includes participation in national committees or leadership roles in professional or academic societies. The resident/trainees should investigate one topic in depth. The outcome of the research/investigation should include a presentation (platform or poster) at a national meeting, or presentation of submission of a manuscript for publication.[2]

The trainees are evaluated at the end of each clinic rotation as well as annually. These evaluations are based on the six core competencies that have been approved by the ABMS and the ACGME. They are medical knowledge, interpersonal and communication skills, patient care and procedural skills, professionalism, practice-based learning and improvement, and system-based practice. In July 2015, the ABPM&R adopted a milestone-reporting process which is a developmental framework from less to advanced skills and knowledge with respect to the core competences for feedback to the trainee and reporting to the ABPM&R.[3] To become board certified, the trainee must pass a written computer-based examination, and after 1 year of independent practice, an oral examination is given by three examiners in different areas of the specialty. Initially, the board certification was lifelong, but in 1993, it changed to a 10-year certificate and introduced the Maintenance of Certification (MOC) program. This program is designed to foster excellence in patient care, ease diplomates into a continuous program of lifetime learning and periodic testing, demonstrate that physicians are maintaining their knowledge and skills over time, document physicians' ongoing efforts to meet the requirements of certification in PM&R and to keep updated in the specialty, and provide assurances to the public that the ABPM&R diplomates maintain and continually improve their knowledge and skills in physiatry. The components of the ABPM&R MOC program are as follows: Part 1 – professionalism and professional standings (an unrestricted current medical license); Part 2 – lifelong learning and self-assessment; Part 3 – assessment of knowledge, judgment, and skills; and Part 4 – improvement in medical practice.[4] This is a continuous 10-year program with status reporting to the ABPM&R and a 160-question computer-based examination taken between the 7th and 10th years of the program. The diplomate is expected to have and document to the ABPM&R their CME credits averaging annually 30 CAT-1 CME credits to participate in self-assessment examinations and a quality improvement program.[4] In the United States, both initial board certification and MOC are voluntary programs, but, in actuality, they are often needed to obtain hospital privileges. Ninety-two percent of those eligible are participating in the MOC programs.[1]

Canada – David Berbrayer

The specialty of PM and R was formally recognized as the 7th medical specialty in 1945 by the Royal College of Physicians and Surgeons of Canada with training requirements on the advice of the committee on training of internal medicine. From the beginning, the Association had decided on the addition of the term “Rehabilitation” to the previously designated title “Physical Medicine.” The Royal College officially changed the name of the specialty to PM&R on June 1, 1955. This action shaped the course and training requirements of future physiatrists.

The residency training program in physiatry is 5 years following medical school. The requirements are set by the specialty committee of the Royal College of Physicians and Surgeons of Canada, and each Canadian medical school undergoes an internal accreditation every 2–3 years and an external accreditation every 5 years. The 5 years of approved residency training must include 12 months of basic clinical training to be completed within the first 18 months of residency consisting of 6 months in internal medicine, which must include at least 3 months of general internal medicine (clinical teaching unit or its equivalent) and 2 months in surgery.

After completion of the training program, the Royal College introduced one five-cycle MOC for all fellows since 2000. This has been modified over the years. Beginning with the new (or next) MOC cycles starting on or after January 1, 2014, all fellows and MOC program participants will be required to complete a minimum of 25 credits in each program section during their 5-year cycle.

As of July 1, 2013, resident affiliates who document learning activities in MAINPORT ePortfolio during their residency program can transfer up to 75 credits (25 in each of the MAINPORT ePortfolio sections of group learning, self-learning and assessment) into their first 5-year MOC cycle following certification and joining the Royal College as a fellow.

Beginning with the new (or next) MOC cycles starting on or after January 1, 2014, all fellows and MOC program participants will be required to complete a minimum of 25 credits in each section of the MOC program during their new 5-year MOC cycle. The annual minimum of 40 credits and a cycle overall minimum of 400 credits are still applicable. There are three sections to be completed as follows: section 1 – group learning; section 2 – self-learning; and section 3 – assessment.

Mexico – Juan Manuel Guzman

In order to certify the professional quality of medical specialists in rehabilitation medicine, the Mexican Board of Rehabilitation Medicine AC was legally constituted according to notarial act number 16232 on September 24, 1973. In November 1974, this Board carried out the procedures to be registered before the National Academy of Medicine of Mexico which granted the Certificate of Suitability in April 1975. The first certification of medical specialists in rehabilitation medicine was carried out in October 1976. In 1993, it was agreed to carry out the recertification with a validity of 5 years.

Currently, there are 290 residents in training at 14 health sector institutions throughout the country. Five have a 3-year program and nine have a 4-year program. After completing the residency training program, the physiatrist may choose to go into independent practice or complete a 1-year fellowship in one of the following seven approved high-level specialties: neurorehabilitation, pediatric rehabilitation, geriatric rehabilitation, electromyography (EMG) and electrodiagnosis, professional rehabilitation, cardiac rehabilitation, and pulmonary rehabilitation.

The resident training program includes assessments at the end of each clinic rotation as well as annually. After completing the residency program, they must submit to the board examination which includes knowledge and clinical examinations. The first part comprises a computerized general knowledge assessment of the specialty questionnaire and the second part comprises inpatient and outpatient assessment. The Mexican Society of PM&R organizes the national conferences for residents who have finished their training program. The Society selects the 25 best resident research papers that they have prepared to obtain their specialty diploma, and these are presented every year with the best three jobs awarded. Thirty-three national conferences have been organized to date. A research forum is also organized every year in order for residents to prepare and present their projects at the national and international congresses.

So far, the board of PM&R has certified 1941 physiatrists and 1000 of them have recertification.

South America – Marta Imamura

In some of the Latin American countries such as Brazil, Columbia, and Peru, residency training programs share similar objectives and content described for the United States. However, board-certified programs, accredited by official national agencies, started much later: 1969 in Columbia, 1978 in Brazil, and in the 1970s in Peru.

The usual curation of the residency programs in most of the Latin American countries lasts for only 3 years, even though the content is quite similar to that described above, except for the inpatient care that has been incorporated in neither Columbia nor Peru. Only one program in Sao Paulo, Brazil, has incorporated inpatient-intensive rehabilitation care into their program.

Research is also a discipline not mandatory or with dedicated program time for its development during the majority of the educational programs in Latin America, with very few exceptions. One example is the clinical research program offered during the PRM residency program at the Institute of Physical Medicine and Rehabilitation in Sao Paulo, Brazil. In this particular program, there is dedicated time to systematically review the literature and design, conduct, and publish the individual research project. On the other hand, all residents are encouraged to develop a research project of monograph as it is a requirement for the board certification process, however without a specific training and dedicated time for this task. Approved subspecialties also vary within different countries, from no existing ones to very few which include electrophysiology, pain, or sports medicine.

  European Union Top

Europe – Maria Gabriella Ceravolo M.D., Nikolaos Barotsis, and Xanthi Michail

The Union Europeenne des Medecins Specialistes (UEMS) was created in 1958 as the only statutory medical body in the European Union (EU) to have a responsibility for hospital-based specialties. It is composed of sections for each specialty. PRM was among the first specialties to be recognized as a distinct discipline. The PRM section was created in 1971. The European Board of PRM was founded in 1991 as a part of the UEMS PRM Section and is responsible for education and training in PRM. PRM is an independent medical specialty in all European countries except Denmark, but its name and focus varies comparatively according to national traditions and laws. At EU level, the monitoring authority for the specialty is the European Board of PRM. At a national level, the training in PRM is regulated by national authorities, which set standards in accordance with national rules and EU legislation as well as according to the requirements of the European Board of PRM.

Training in physical and rehabilitation medicine

Training usually lasts between 4 and 6 years depending on the country. Specialists in PRM have freedom of mobility across UEMS member states, but require certification from their national training authorities. The PRM board advocates a duration of training of 60 months including 12-month rotation in external departments (such as internal medicine, neurology, orthopedics, intensive care unit [ICU], and others). Moreover, it is highly recommended that PRM trainees be exposed to basic training in research methodology and be involved in ongoing research projects at university hospitals for a minimum of 6 months as a mandatory component of their postgraduate education. Where part of the training is spent in units of other specialties, they themselves must also be approved as training institutions by their national responsible authority. The route to start training is slightly different in each country, but despite different entry points to the specialist training program, the curriculum has much similarity across the continent and is consistent with that of the American Board. The European Board of PRM, having the task of harmonizing specialist training across Europe, has taken on the following roles:

  1. European examination for recognition of specialist training. PRM specialists who pass the examination become fellows of the European PRM board
  2. Continuing professional development (CPD) and medical education with 10-year fellowship revalidation
  3. Recognition of European trainers through the assessment of their professional and scientific career
  4. Recognition of training units through site visits.

The head of the training institute should be a PRM board-certified specialist. The eventual aim of this harmonization is to produce specialists who can work across European health-care systems and allow national medical authorities/employers to recognize the knowledge and expertise of the specialists who have been trained in another part of Europe. The trainee should gain experience of the diagnosis and management in the areas defined in the curriculum of studies and program of theoretical knowledge.[4] PRM trainees must acquire a number of skills as part of their training. Their basic medical training gives them certain competencies which are enhanced by knowledge and experience acquired during their common trunk training in internal medicine, neurology, orthopedics, etc. The core specialty competencies of PRM are provided during their specialist training.[4] Subspecialty competencies are under development in some European countries (e.g. rehabilitation of patients with spinal cord injury, rehabilitation of patients with musculoskeletal disorders and amputations, and sport rehabilitation)

The European Board of PRM has developed a comprehensive system of postgraduate education for PRM specialists. This consists of the following:

  1. A curriculum for postgraduate education containing basic knowledge and the application of PRM in specific health conditions
  2. A standardized training course of at least 4 years in a PRM department and registered in detail in a uniform official logbook. Trainees should keep their personal log book and present this before certification. It contains reports from the trainer giving an account of his or her active participation in the work of the unit, their publications, scientific and research works, including relevant theses. The European Board attaches considerable importance in the details of the training program as shown in the logbook of each candidate
  3. A system of national managers for training and certification to foster good contacts with trainees in their country
  4. Standard rules for the certification of trainers and a process of certification
  5. Quality control of training sites performed by site visits of certified senior specialists
  6. CPD within the UEMS covers the continuing medical education (CME) system for the purpose of 10-year recertification.

Maintenance of certification

CPD and CME are an integral part of medical specialists' professional practice, and the European provisions are the same for all specialties. CPD covers all the aspects of recertifying medical practitioners, of which CME is one component. PRM specialists in Europe need to demonstrate their continued competence like all other doctors. Various teaching programs have been implemented across Europe, which serve to educate PRM specialists and their colleagues in rehabilitation teams. These cover basic science and clinical teaching topics, as well as investigational and technical programs. CME and CPD programs are organized on a European level for accreditation of international PRM congresses and events. The programs are based on the provisions of the mutual agreement signed between the UEMS European Accreditation Council of CME (EACCME) and the UEMS-PRM Section and Board. The UEMS EACCME is an institution of the UEMS which formally represents European countries. The PRM Board has created the CPD/CME Committee, which is responsible for the relevant continuing programs within our specialty for the accreditation of the several scientific events on European level. The EACCME is responsible for coordinating this activity for all medical specialties, and the UEMS website provides details of the CME requirements for all specialists in Europe (www.uems.eu). It is recommended for the European PRM Board-certified specialists to collect annually 50 CME credits. The recertification of European PRM Board Fellows requires a total of 250 CME credits over the last 5 years. The PRM Board also takes the responsibility of enhancing the opportunities of education for PRM trainees and young PRM physicians through sponsoring international teaching programs and delivering educational materials. Further information on the regulations of this education and training system is available on the UEMS PRM Section's website, www.euro-prm.org, where application forms are also available.

  Asia Top

Japan – Nobuhiko Haga

The Japanese Association of Rehabilitation Medicine (JARM) was established in 1963 and started to hold postgraduate training courses two or three times a year, due to few medical schools having departments in PRM. From 1975 to 2002, there were 58 postgraduate training courses.

In 1980, the JARM established a system of certifying experienced medical doctors specialized in PRM which led to the today's system of board-certified physiatrists. In 1987, the JARM began another system to certify medical doctors practicing PRM in certain medical fields such as orthopedics, neurology, neurosurgery, and pediatrics, which led to the system used today of registered rehabilitation physicians. As of March 2017, there are 2279 board-certified physiatrists and 3603 registered rehabilitation physicians. In 2003, the fundamental principles for education of rehabilitation medicine with the curriculum indicating specific objectives were determined.

After completing 2 years of postgraduate clinical training in various fields of medicine, the doctor must receive specialty training for PRM in an institute certified by the JARM for at least 3 years. When the training curriculum defined by the JARM is achieved, he/she will take an examination to be a board-certified physiatrist.

In 2014, the Japanese Medical Specialty Board, a national organization for resident training, was established, which is planning to integrate a postgraduate specialty training system in 19 basic medical fields including PRM and will start a new training system in 2018. Starting in 2018 with the new training system, the duration of training is 3 years or longer and each resident belongs to one training program, each one composed of one central and one or more affiliated training institutes certified by the JARM. During the training period, a resident is trained at the central institute for at least half a year and at affiliated institutes in the residual period. These institutes include university hospitals, rehabilitation centers, general hospitals, and rehabilitation clinics. He/she must work for one or more hospitals with a recovery-phase rehabilitation ward for at least half a year during the training period. Over seventy training programs are present in Japan.

The training contents that each resident must achieve during the training period are decided in the training curriculum and include general knowledge on PRM and related medical fields, patient diagnosis, rehabilitation treatment, learning attitude/lifelong learning, and ethical/social/other knowledge. In addition, each resident must experience at least 100 patients during the training period, including 75 minimal requirements in cerebrovascular brain injury, spinal cord injury, musculoskeletal conditions, pediatric conditions, neuromuscular conditions, amputations, internal organ disabilities including cardiac and pulmonary rehabilitation, and other diseases or causes needing rehabilitation. Residents are also encouraged to experience community-based rehabilitation.

When the chief officer of the training program certifies that the resident has achieved all the training curriculum, the resident will take and pass a written and an oral examination to become a board-certified physiatrist. This accreditation is limited for 5 years. To renew, a board-certified physiatrist must fulfill the requirements determined by the JARM, including attending annual JARM meetings, taking instructional lectures and seminars, presenting papers in medical conferences, and publishing articles in medical journals. This renewal system is managed by the Japanese Medical Specialty Board and JARM.

The system for subspecialty training has not been developed in the field of PRM, but the JARM is planning subspecialty systems for phase-related rehabilitation medicine, i.e. acute-phase, recovery-phase, and maintenance-phase rehabilitation. In addition, the Japanese Society of Prosthetics and Orthotics, in cooperation with the JARM, is currently developing a system for certifying board-certified physiatrists with special interest and experience in the field of prosthetics and orthotics as a subspecialty.

Starting in 2018 with the new specialty training program, the Japanese Medical Specialty Board will approve dual certification for doctors in specialties such as orthopedic surgery and neurosurgery after completing at least 2 years of specialty training in PRM and passing the required examinations.

China – Jianan Li

Chinese resident training was started in the 1980s and developed during the 1990s to 2013. The training was conducted by hospitals without national standards and programs. All medical graduates were employed after graduation by hospitals and then enrolled in 3-year resident training programs organized by the hospitals.

The first rehabilitation resident training program was drafted by the Rehabilitation Branch, Chinese Medical Doctors' Association, which was established in 2003. However, the program was not implemented due to lack of financial support and consensus on training programs as well as organizational structure. Even though teaching materials, examination packages, as well as certification were discussed for 10 years, the implementation of the rehabilitation training program did not start until December 31, 2013, when the national medical resident training was finally decided by the National Health and Family Planning Commission and six other national government departments. Formal implementation of the program throughout China started in 2015 when the financial support was allocated from the national budget. Since then, all medical graduates may have 30,000 YMB year allowance per person from the government budget for their training period plus stipends from the hospital where they have their training. About 500 tertiary hospitals were accredited as the national training bases for rehabilitation resident training. It is planned to train 500,000 medical residents and to complete resident training systems by 2020. By 2016, more than 80% of medical graduates enrolled in this national resident training program. However, the major challenges remain such as a national standard for mid-term and final examinations, subspecialty training programs, quality control of the training process, and accreditation.

The general structure of Chinese rehabilitation resident training is 5-3-X. The “5” refers to 5-year education in a medical university. The “3” refers to 3-year general training for a rehabilitation doctor. The purpose of this general training is to build up competence in clinical practice of general rehabilitation medicine, self-learning skills, clinical research, as well as teaching. The “X” refers to 2 to 4-year training for a subspecialty in rehabilitation, including neurorehabilitation; spinal cord injury rehabilitation; orthopedic, pediatric, geriatric, and cardiopulmonary rehabilitation; as well as pain management.

The 1st year rotation is in relevant clinical departments to understand and become familiar with principles and methods in the diagnosis and treatment of common diseases and health conditions. These clinical departments include neurology, orthopedics, ICU, neurosurgery, cardiovascular medicine, respiratory medicine, rheumatology, pediatrics, clinical image, EMG testing, or cardiopulmonary exercise testing. After this year of training, the resident needs to pass the national doctor's license examination and then is qualified to be the trainee in the 2nd and 3rd years. This duration of the residency involves competence training in inpatient and outpatient management, rehabilitation therapy, neurological rehabilitation, orthopedic rehabilitation, cardiopulmonary rehabilitation, and pediatric rehabilitation, as well as outpatient service and rehabilitation of other selective subjects.

All trainees who completed the 2nd and 3rd year training will take part in face-to-face examinations (objective structured clinical examination), including clinical examination, diagnosis, patient records and analysis, electrocardiography, X-ray and EMG reading, clinical reasoning, discharge planning, rehabilitation, and clinical management. The examination will be conducted at the provincial level.

Taiwan – Tyng-Guey Wang and Alice M. K. Wong

The National Taiwan University Hospital (NTUH) officially established the Department of Physical Medicine and Rehabilitation in 1962. In the following 10 years, Dr. I-Nan Lien, who was trained at New York University in the United States, made strenuous efforts to promote cooperation among rehabilitation physicians, physical therapists, occupational therapists, speech therapists, prosthetic providers, psychotherapists, and social workers to form a complete rehabilitation team. Meantime, the Tri-Service General Hospital and the Veterans General Hospital also established their disability reconstruction center, and the Cheng Hsin General Hospital launched a rehabilitation center as did many other medical institutions covering nearly all of Taiwan (approximately 35 qualified rehabilitation resident training centers).

The Taiwan PMR Academy was founded in 1971 and its membership has grown to 1100 members in 2017. Only certified rehabilitation physicians are qualified as the formal members who have the right to vote for, and/or run as a candidate in the election for an official position in the Taiwan PMR Academy. However, it does accept rehabilitation residents as a candidate member and they can participate in various affairs of the academy except the election. In the last 10 years, the academy has aggressively taken part in many international rehabilitation programs such as conferences, workshops, and symposiums. The annual rehabilitation-related publications of Taiwan in science-cited indexed journals is about 300–350 articles.

In 1968, the NTUH began a formal rehabilitation specialist training course for resident doctors. To become a certified physiatrist, one had to graduate from the department of medicine of various universities with a physician's license followed by a PMR residency training. In 1969, the hospital began to offer to the 6th-year medical students a two-credit elective course in rehabilitation medicine and also a three-credit rehabilitation internship course to the interns (7th-year medical students.) In 1984, the Taiwan PMR Academy held for the first time a PMR Board examination including both written and oral tests. In 1987, the Taiwan's Administration of Health officially recognized rehabilitation specialist licenses and commissioned the academy to hold a board examination annually.

The Taiwan's Ministry of Education made PRM a compulsory one-credit course for medical students in 1974. This consisted of 18 h of lessons on rehabilitation medicine. The interns in their 7th year were offered elective courses including a 3-week clinical practice and other comparatively in-depth courses.

To train more PRM specialists, university hospitals and other large hospitals gradually introduced rehabilitation training programs for residents. These programs were to be evaluated by an established set of criteria. At that time, it was stipulated that a hospital with at least two full-time-certified PRM physicians could train two residents per year. The hospital was required to have a complete rehabilitation team able to provide physical, occupational, and speech therapy as well as provide outpatient services at least four times a week; allocate to the PMR department a minimum of ten inpatient beds (or 1% of its total beds); and provide EMG diagnosis, bladder dynamics, and musculoskeletal ultrasound. The evaluation of a rehabilitation resident training center was conducted every 3 years. Hospitals that met the criteria could recruit new residents for PRM training. A new set of criteria was introduced after 1999 and since then, the PRM department of a hospital must have at least three certified physiatrists if it wants to train two residents per year. In 2017, it changed to at least five certified physiatrists to train rehabilitation residents. During the training period, an annual written examination is required.

The board examination of PMR in Taiwan is held once a year and includes both a written and an oral part. During the PMR residency, a paper in a peer-review rehabilitation-related journal bearing the name of the resident as the first or co-author is required before being a candidate for participation in the examination. The candidate must pass the written part before taking the oral examination which is divided into eight to ten sections according to the decision of the Education Committee Board.

The rehabilitation medicine in Taiwan is generally organized into four subspecialties which are neurorehabilitation, orthopedic rehabilitation, pediatric rehabilitation, and cardiopulmonary rehabilitation and presently, there are no subspecialty examinations.

South Korea – Sun Gun Chung

PM and R in South Korea can be traced to 1951 when the American–Korean Foundation was established after Dr. Howard Rusk's visit to Korea in the midst of the war. The Korean National Rehabilitation Center was founded in 1953 under the auspices of the United Nations and the American–Korean Foundation. The Korean Academy of Rehabilitation Medicine (KARM) was founded in 1972 which was approximately the time when PM and R academic societies were organized in Taiwan, India, Iran, and the Philippines. The first edition of the official journal of KARM was published in 1977.

Residency training programs began in 1983 with a 3-year term in addition to a 1-year internship. In 1990, the PM and R residency training was extended to 4 years. The number of residents in training was 13 in 1983 and that has increased to 130 per year in 2012. Currently, 83 training hospitals provide PM and R residency programs and most programs are affiliated with independent PM and R departments that are established in forty medical schools. As of 2016, almost 2000 physiatrists have been board certified.

Training curricula vary from hospital to hospital, but should be based on the training goals suggested by the KARM, which are to acquire knowledge and skill to evaluate and treat persons with disabilities and to practice evidence-based medicine. Training programs generally include neurorehabilitation, spinal cord injury rehabilitation, musculoskeletal rehabilitation, electrodiagnostic medicine, pediatric and geriatric rehabilitation, cardiopulmonary rehabilitation, sports rehabilitation, orthotics and prosthetics, physical medicine, and cancer rehabilitation. The length of rotation and the number of supervising physicians vary in each training program. While each training program has its own curriculum developed in accordance with the expertise of the comprising staff physiatrists, 1st-year residents (immediately after their internship) are usually exposed to neurorehabilitation and spinal cord injury rehabilitation, taking charge of inpatient care. From the 2nd year, residents begin to take part in musculoskeletal rehabilitation, electrodiagnostic medicine, pediatric and geriatric rehabilitation, cardiopulmonary rehabilitation, sports rehabilitation, orthotics and prosthetics, physical medicine, and cancer rehabilitation under the supervision of staff physiatrists specialized in each subspecialty. As the resident advances, more autonomy is granted in taking care of patients, but suitable supervision is to be provided at any time.

In-depth training for each subspecialty is mostly done in fellowship programs. Currently, this subspecialty training is active in neurorehabilitation, spinal cord, pediatric, and musculoskeletal rehabilitation. The fellowship programs in each subspecialty are solely functional because yet no formal accreditation for subspecialty training has been established.

For quality control purposes, the KARM publishes and distributes standard logbooks for new trainees every year. This logbook contains a list of training goals that include minimum clinical requirements. Each resident should clinically manage at least 300 inpatients and perform 200 electrodiagnostic examinations during the 4-year period. Each trainee is required to document his/her clinical activities in a standard logbook. A trainee must submit this logbook to the KARM to be qualified for the board certification examination. Another quality control activity for training programs is the annual in-training examination. All PM and R residents are required to take the examination, after which the national ranking of each trainee is reported to him/her by the chair of the department.

Mandatory academic activities are also set by the KARM. To be qualified to apply for the board certification examination, a PM and R trainee should publish at least two original research articles in high-quality medical journals. One of the two articles should be published in the Annals of Rehabilitation Medicine, the official journal of KARM, with the trainee as the first or corresponding author. Regular participation in annual meetings and educational symposia of KARM is another requirement.

Although the Ministry of Health and Welfare has the authority to grant board certification to applicants, the Korean Medical Association (KMA) oversees and implements board certification examinations. The examination committee of the KMA is in charge of the examination for PM and R board certification in collaboration with the KARM. The examination consists of two parts. The first is a written examination. The second part used to be an oral examination, but this was discontinued in 2012 because of the rapid increase in the number of board applicants, resulting in too much of administrative and financial burden. The KARM transformed the second part into an audiovisual test consisting of 100 test questions with medical images and 20 questions with video clips. The average pass rate per year for the PM and R board examination is approximately 95%.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Personal Communication, American Board of Physical Medicine and Rehabilitation; 2017.  Back to cited text no. 1
ACGME Program Requirements for Graduate Medical Education in Physical Medicine and Rehabilitation; Revision 8 February, 2016.  Back to cited text no. 2
American Board of Physical Medicine and Rehabilitation website-8 February 2016.  Back to cited text no. 3
European Physical and Rehabilitation Medicine Bodies Alliance. White book on physical and rehabilitation medicine in Europe. Chapter 2. Why rehabilitation is needed by individual and society. Eur J Phys Rehabil Med 2018;54:166-76.  Back to cited text no. 4


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