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Pediatric rehab docs hope new board certification will attract more to field
Pediatric rehab patients currently being served by a dedicated few
In pediatrics, pharmaceuticals, and parenting, it has long been known that children are not just miniature adults. In the field of rehabilitation, that knowledge has been a little slower coming into practice.
There are at most 150 physicians practicing pediatric rehabilitation in the United States, says Dennis Matthews, MD, professor and chairman of the department of rehabilitation medicine at the University of Colorado School of Medicine. Matthews also is medical director and chairman of rehabilitation medicine at The Children’s Hospital in Denver and holds the first endowed chair for pediatric rehabilitation in the country.
Most of those physicians are stretched to the limit, finding many more patients who need their care than they possibly can see in a timely fashion. It is not unusual around the country for patients with chronic issues to have to wait as long as six months to get an appointment. It can take months, if not a couple of years, to fill open positions for pediatric rehabilitation specialists. There just aren’t enough doctors to go around.
In California, the situation is particularly dire. There only are 10 physicians dedicated to pediatric rehab in the entire state, says Robert Haining, MD, division chief of physical medicine and rehabilitation at Children’s Hospital and Research Center at Oakland. Haining has been trying to fill two physiatrist positions for two years.
With insurance and reimbursement problems, coupled with the high cost of living, California just can’t compete in the small pediatric rehab physician pool, he explains. At the same time, the number of potential patients continues to increase with strides in such areas as neonatal intensive care. "Kids with cerebral palsy get saved in the nursery because we don’t let them die like we used to," Haining says. "Then they have to find a place to hang out, and that’s generally in the rehab world. We have very limited facilities statewide."
When those kids are seen in rehab, they usually are much sicker than their adult counterparts. "We take kids straight out of the ICU [intensive care unit] because there is no nursing home to put them in," Haining says. "That means we have kids with IVs, central lines, on ventilators on a rehabilitation floor whom you would not generally have on an adult floor."
Rehab physicians need the extra training to work with kids. But many choose to stick with adults rather than go through the extra pediatric fellowship and potentially make as much as 40% less money in pediatric rehab, he adds.
Experts in the field hope to see that situation improve now that physicians can become board-certified in pediatric rehabilitation. Last November, the American Board of Physical Medicine and Rehabilitation (ABPMR) based in Rochester, MN, offered the first pediatric rehabilitation subspecialty exam. Forty-four physicians passed the exam.
"We hope the exam will give more credibility to the field," says Maureen Nelson, MD, director of pediatric rehabilitation services at the Charlotte (NC) Institute of Rehabilitation. "It should bring more awareness to people who have never heard of pediatric rehabilitation. We hope that means we can have a big impact on even more kids."
Nelson, chairwoman of the American Academy of Physical Medicine and Rehabilitation’s special interest group on pediatric rehabilitation, says interest in the field has been growing steadily over the past decade. "When I started going to the pediatric rehab meetings, there would be maybe 30 people. Now we’ll have 150 to 200," she says.
The special interest group is working to provide quality continuing education and write guidelines that would help make rehab care specific to children and consistent across the country. The group also is working to increase exposure to the field in hopes of attracting more medical students.
"It is horrendous how long people have to wait to get in to see us," Nelson stresses. "Right now [in January], you can’t get an appointment until June. That is not how it should be. Of course, with urgent issues, we find a way to make it happen but a lot of children have chronic issues, and they just have to wait."
Some basic treatment issues overlap, of course, between adults and children. But the main difference is children still are growing physically, cognitively, and emotionally. "The big difference in pediatric rehab is that we have training with children. One of the most important things I have in my pocket is bubbles, as opposed to an adult doctor. Bubbles are fun, but I can also tell a lot clinically by how the child responds," she says. "We are in tune to the developmental impact on the child, and how their problem will impact their growth both cognitively and physically."
One of the unusual aspects of Nelson’s practice is a twice-monthly brachial plexus injury clinic where she and an occupational therapist see children from newborns to teens. "This happens in two out of 1,000 babies, and most people have never heard of it," she explains. "Besides the clinical care, this is a social opportunity for the kids and their parents. It’s helpful for the parents to know they are not alone. It’s good for parents of babies to see a family with a 3-year-old and get that mom’s advice in the waiting room."
In Denver, Matthews and three other physicians see 7,000 patients a year. "We’re as busy as we want to be, but we’re still probably only seeing a very small number of the patients who could really be helped by pediatric rehab medicine," he says.
Matthews serves on the board of directors for the ABPMR and helped write the questions for the new pediatric rehab exam. To take the exam, the majority of a physician’s practice has to be pediatric rehab medicine. Until 2007, physicians can qualify for the exam with a combination of completing a residency and demonstrating years of clinical experience. After 2007, physicians must successfully complete a residency and fellowship training in pediatric rehab medicine to take the exam.
"We think this will increase the number of programs around the country, resulting in more fellowships," he adds. "What this will really do is develop a uniformity in training and improve the quality of education for the residents. The second thing it will do is continue to expand the field because it will provide a group of people interested in education, training, and research in pediatric rehab. We expect the knowledge of the field to increase exponentially."
Some children may be seen by adult rehab physicians or by a developmental and behavioral pediatrician, a neurodevelopmental specialist or a pediatric orthopedist. But for the total rehabilitation package, more kids need to be seen by pediatric rehabilitation specialists, Matthews says.
"We’re most interested in function and reintegration of the kids into the community. We’re interested in school re-entry, participation in activities, recreation, quality of life," he notes.
"We have particular expertise with children with developmental or early-acquired disability. If a baby or a child has a stroke, the whole issue is how do you separate out what is normal development vs. what is the effect of the brain injury, and how do you help facilitate recovery or compensation," Matthews continues.
Pediatric rehab specialists also work to incorporate parent, sibling, and school issues into the treatment process. Matthews’ team is working now on a research project on school performance issues for kids with brain injuries.
"Physically, they restore," he says. "It’s the learning, memory, and attention issues that are problematic. The attention, behavior, and cognitive issues can be difficult for teachers to deal with in the classroom."
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