key: cord-0875538-zw8rfvkg
authors: Stautzenbach, Thomas E.
title: Demonstrating the vital role of physiatry throughout the health care continuum: Lessons learned from the impacts of the COVID‐19 pandemic from a national academy perspective
date: 2021-06-07
journal: PM R
DOI: 10.1002/pmrj.12614
sha: 0544e85d2891e05a75d1d80113da0696c95c327b
doc_id: 875538
cord_uid: zw8rfvkg

nan

Speculators, fortune tellers, and psychics have flourished during prior periods of unprecedented and unnerving national calamity. Our current situation is no different, although the players have been polished up as they make bold predictions regarding the implications of the worldwide COVID-19 pandemic on our future society and health care system. Management consultants are feverishly publishing and offering their premium services to share prophecies around the consequences and fundamental change that will result from our current crisis. Many variables across our society, including social and political unrest, are in simultaneous state of change making detailed predictions about the future more speculative than ever. Although it may be too early to accurately predict the future, we can and should look to the broader trends that existed before the pandemic that are now under more scrutiny and pressure in today's environment.

The pandemic has accelerated many existing precrisis trends and has dramatically uncovered the fragility of our health care system. The inequities and social implications of our fragmented delivery system and national health care funding strategies have been undeniably exposed. Future analysis will surely document the outcome variances between communities that were able to respond to the pandemic with an integrated health care response compared to those communities that lacked the system integration and cooperation to marshal a comprehensive response. The instability of our existing health care finance and reimbursement system, which necessitates and prioritizes specialized procedures that must subsidize general and intensive medical care, has brought many of our largest and most prestigious health care systems to their brink with implications that will last much longer than the pandemic itself. The vulnerability of private and group medical practices with limited financial reserves and access to capital has resulted in long-term uncertainty for many practices.

Positively and appropriately, front-line physicians and health care workers have been praised and their professional reputations elevated for heroic actions and personal sacrifices responding to the COVID-19 pandemic. So too have physiatrists been deployed to the front line and have converted rehabilitation units and innovatively reengineered practices to maintain crucial continuity of care for the most vulnerable patients. The rapid response and inspiring achievements of medical science and research have moved from scientific journals to front-page news.

Yet these merited accolades for the medical community are coming during a time of great hardship and disruption in the profession. Temporary practice closures and the ongoing significant reductions in patient volume, combined with higher practice expenses (e.g., personal protective equipment [PPE] and other safety investments) threaten the stability of physician practices and are creating profound fiscal and emotional stress on practitioners at the very time they are being asked to step forward. Surveying by the American Academy of Physical Medicine and Rehabilitation (AAPM&R), as well as the American Medical Association, illuminate these innovations, disruptors, and stressors. A survey of AAPM&R physiatrists (supplemental Appendix) indicates that 6.7% of respondents reported that their inpatient rehabilitation facilities (IRFs) closed (27% partial bed closings), 4.5% of IRFs were turned into acute COVID-19 units, 7.9% of IRFs were converted into acute non-COVID acute hospital beds, and 31.5% of IRFs created dedicated IRF COVID-19 recovery units. In addition, 20.2% of the affected physiatrists reported being deployed to care for acutely ill COVID-19 patients in the inpatient setting and 68.5% reported caring for recovering post-COVID-19 patients. Procedures in private practice settings and institutions were halted or significantly reduced for safety protocols as well as bed capacity and PPE rationing. Five to 6 months into the pandemic, American Medical Association research 1 reports an overall drop in physicians' revenues averaging 32%, as 70% were still experiencing fewer total patient visits, inclusive of telemedicine, than prepandemic volumes. Combined, these effects have further exasperated the already alarming levels of burnout in the medical profession.

Of utmost concern, and potentially a predictor of significant substantive change, may be the question that many physicians are quietly asking themselves -"Who's got my back?"

Amid the pandemic, with physicians stepping forward, taking risk, and making significant personal sacrifice, many are also looking at the government and their employers with dismay. While responding to their professional code and responsibility, often in conditions without appropriate PPE, physicians are also experiencing compensation reductions and other unwarranted assaults that are compounding the professional crisis. Large health care systems, with billiondollar endowments and reserves, have reduced physician compensation while concurrently increasing workload expectations. Physicians are being asked, or required, to reduce or eliminate future time off to make up previously reduced relative value units. Private equity practice owners are tightening the productivity screws while concurrently reducing efficiency bonuses. Professional development resources are being frozen or curtailed at the same time physicians are being asked to expand their care into new and unfamiliar areas. Government, although being commended for providing practitioners and practices with fiscal relief plans and regulatory flexibility, continues a long-term assault on medicine by threatening deep reimbursement cuts (e.g., Centers for Medicare & Medicaid Services 2021 Proposed Physician Fee Schedule) during a fiscal recovery that has put medical practices in jeopardy. In PM&R, during a pandemic that is sure to have profound long-term recovery and medical rehabilitation patient needs, the Centers for Medicare & Medicaid Services had the impudence to propose allowing nonphysician providers to replace essential physiatry medical functions. There should be no question why medicine is seeing a substantive increase in early physician retirement and those simply walking away, which will compound the prepandemic physicianshortage.

Professional medical associations Professional medical associations have been challenged to reexamine their purpose and portfolio of value because of significant and accelerating changes in the market they serve and the historical functions and value they provide. Inexpensive continuing medical education (different from high-quality education) has become an overabundant commodity; digital and open access evolutions have changed publications, and external social networking alternatives have threatened the unity and alignment of the professional community. Traditional partners have become competitors. Fiscal support for advocacy and research has struggled with the changing business model that has devalued traditional revenue streams needed to support the longerterm and often less tangible outcomes. More so, the house of medicine has struggled to come together with clarity and focus that truly unites the voice of medicineacross all the specialties, subspecialties, and disciplines.

The pandemic, with its disruption to the health care system and the simultaneous chaotic political environment, has thrust professional medical associations to the forefront and spotlighted their role, impact, and value. AAPM&R, our peer national medical specialty societies, the American Medical Association, and the Council of Medical Specialty Societies individually and collectively through coalitions, have worked to represent and unify the voice of physicians through this public health crisis. The crisis has highlighted the strength of the professional medical associations to stand together across disciplines and specialties to remove barriers to care and unnecessary regulations and restrictions hindering crucial flexibility and to collectively advocate the government for urgent fiscal relief and support for physicians and medical practices to support the fragile health care infrastructure during the crisis. Although there is clearly significant work ahead, both during the pandemic and eventually to sort out the aftermath, the crisis to date has highlighted the critical importance of these organizations and value to the professions and specialties they represent.

The events of this past year have forced a return to the basic tenets for associations and celebrated the unique and indispensable value to the profession. At their core, "associations are a group of people who voluntarily come together to solve common problems, meet common needs, and accomplish common goals" (Tecker International, Glenn Tecker, principal) -and that is what we saw brilliantly on display in 2020. Specialty societies united to confront the pandemic as well as unprecedented political attacks on medicine. Critical resources were shared across specialty societies. Within PM&R, subspecialty distinctions and barriers were minimized as physiatry united in a time of need. Physiatrists came together in the AAPM&R infrastructure to support each other -create critical resources, share experiences and insights, advocate for urgent support and crucial flexibility, and unite their voices in defense of the specialty when under attack. A common sense of purpose and urgency further strengthened and energized the already strong respect and camaraderie between member volunteers and professional staff. We united as a comprehensive community, pulling in the same direction and lending a hand to assist each other in this extreme time of need. Previously defined annual plans quickly pivoted to address new realities. We worked as a community to provide valued resources and equally important an essential ear and virtual hug when needed to get through the unprecedent day-to-day challenges. Our collective actions defined the meaning and value of an association as a professional home.

Similar to the constraints of predicting the long-term impact of the COVID-19 pandemic on the health care system, it may be too early to fully understand the lessons learned that can guide the future trajectories of medical specialty societies. However, professional medical associations have already demonstrated that they had the physicians' backs when doctors felt abandoned by other institutions during these tumultuous times.

The crisis is proving the strength and need for professional communities -and a community beyond simply what is attainable in an online social network. These times require a community that enables members to socially network but also an infrastructure that enables the collective energies, talents and passions to generate time urgent resources that can immediately impact practices and lives. The immediate sharing of experiences and lessons learned during the pandemic, and the subsequent translation of those insights into high-quality and unbiased education, resulted in substantive value for members and their patients.

High-quality, unbiased education will remain a cornerstone of medical specialty societies. The digital revolution was already underway, although the recent circumstances have rapidly accelerated the trend and propelled innovation. Virtual education quickly expanded the outreach for engagement across the entire membership, eliminating previous barriers to participation. Just as telemedicine is challenging prior assumptions regarding boundaries for clinical care, virtual education will be further pushing the frontiers in augmented reality and simulation to challenge outdated assumptions for what can be taught remotely and with the exciting ability to reach significantly expanded audiences.

Whereas the digital revolution in education may be the preexisting trend that gets accelerated the quickest and most visibly, advocacy may be the most profoundly affected by our current experience. The early lessons learned underscore the impact the unified voice of medicine can have when it truly works together -something that has historically been difficult across the specialties of medicine as well as within the clinical diversity of a specialty such as PM&R. The PM&R advocacy functions have been traditionally challenged in terms of scope/breadth, strategic influence, and resource capacity. The aftermath of the crisis and detrimental impact on the current health care infrastructure will clearly demand unprecedented levels of advocacy engagement. The lessons learned to date direct us to tightly focus our energies on unifying issues within the PM&R specialty and across the house of medicine and expand our current paradigm of advocacy beyond the traditional legislative and regulatory institutions to new stakeholders that will be instrumental in the redesign and recovery of the health care system. Furthermore, the advocacy lesson learned is to further prioritize and accent immediate and tangible member needs -to have our members' backs when they have been abandoned and are being attacked by others. The goal of course is not new, but a new approach may very well be necessary. Professional medical societies are granted nonprofit, tax exempt status for our mission to serve the public good. By advancing the education, science, and professional discipline, we are ultimately advancing high-quality care for the public. Yet one can foresee the necessity for the pendulum to swing to further "represent" the needs of the profession during a potential period of critical health care introspection and reconstruction. Will medical societies forgo their Internal Revenue Service status and reconstitute and trend toward taking the form and function of physician unions to more formally have a seat and strong respected voice at government tables and with employers? Will physician members willingly allocate the required resources, comparative to other professions and trades, to support a more robust representation?

More important, will the future medical society advocacy agenda reflect a posture of guarded defense of the profession or proactive vision comprehensively addressing the health care challenges facing our nation? A great deal of current advocacy effort is defensive in response to not only the government and political agenda but also the constructs of institutions created within medicine, by medicine.

Therefore, although recent lessons have highlighted the value of advocacy and future expectations necessitate the amplification of our unified voice, the real dilemma is a strategic choice: do medical societies best protect their members -have their backs -by defending or by stepping outside the current advocacy lanes and roles to proactively lead and set a new vision for health care? In a sports analogy, does offense or defense win games? The answer likely depends on how one views the current situation, and we know these stakes are not a game. Do we believe the pandemic is a short-term crisis and our advocacy efforts are designed to support our members ability to navigate, survive, and return to "normal," or do we believe that the pandemic will result in transformational changes in health care and thus we must refocus our advocacy efforts toward influencing substantive and sustainable change in our health care system?

The pandemic's unprecedented disruption threatening the sustainability of our health care system and the indisputable unmasking of our country's health inequities are sure to be priority focuses of the incoming administration. Medical societies' advocacy strategies that do not specifically address these harsh realities will likely fall on governmental deaf ears and be interpreted and quickly dismissed as self-serving. Can organized medicine step to the forefront, assume and recapture the leadership mantle with a unified vision and plan for how to reconcile the current catastrophe, and in doing so regain and reassure medicine's leadership for the future? To do so will necessitate that the house of medicine also challenges some of its own archaic defensive stances and lines-in-the-sand. It will require accepting the national realities of unstable health care expenditures, growing resource limitations, and the overall needs of teams and the multidisciplinary health care workforce issues beyond the physician community. It will require us to honestly grapple with the broad perspectives and realities of scope of practice. Gaining consensus within the profession for what defines our advocacy priorities and new strategic approaches, and a deeper understanding and commitment of society members to personally support those efforts lies at the crux of the challenge and opportunity for medical specialties.

Medical specialty associations have traditionally demonstrated value through reaction when confronted. When there is a distortion in the environment, members mobilize by joining within their professional association to respond productively and with impact. We must remain keenly alert to the long-term implications of this moment in history and how it has challenged our paradigms and altered our assumptions of the future. The AAPM&R can expand on the forced momentum of the crisis to further build the cohesiveness and unity of our actions and voice. PM&R BOLD is an AAPM&R attempt to be more proactive, to create a future that benefits the specialty's trajectory, each member, and their patients. As we continue to learn of the long-term outcomes and lessons of the COVID-19 pandemic, AAPM&R must refine its advocacy goals and innovate its strategic approach to represent the specialty in what will undoubtedly continue to be unprecedented times. AAPM&R will aggressively advance education and advocacy that support practice optimization and survival with emphasis on priorities related to critical reimbursement, as well as setting and defending appropriate professional standards and advancing outcome data. What is also emerging is an energetic return to association principles and a renewed innovation around the valued core attributes of a professional community. Medical societies must strengthen the peer-to-peer infrastructure and member community support that differentiates them from other business enterprises and relationships. We must prioritize member well-being to mitigate the impact of disruptive change, isolation, and professional burnout. Lessons to date have confirmed that there is a strong necessity for the medical society, a desire and need to build professional community, and a demonstrated impact that organized medicine can effect change. Together as a community we will have the backs of physiatrists.

COVID-19 Physician. Practice Financial Impact Survey Results

Additional supporting information may be found online in the Supporting Information section at the end of this article.How to cite this article: Stautzenbach TE. Demonstrating the vital role of physiatry throughout the health care continuum: Lessons learned from the impacts of the COVID-19 pandemic from a national academy perspective. PM&R. 2021;13:605-608. https://doi.org/10. 1002/pmrj.12614