The field of physical medicine and rehabilitation attracts many physicians with unique skills and interests, both inside and outside of clinical medicine. Although I began my resident journey believing I would pursue advanced training in spinal cord injury through a clinical fellowship, I eventually realized that I enjoy many other areas in our field and prefer to practice general physiatry. I also became more interested in healthcare delivery, specifically the quality and policy of rehabilitative care. Through my involvement with our local quality improvement (QI) committee, I was introduced to my current fellowship (Chief Resident in Quality and Patient Safety, CRQS), which has opened countless opportunities for professional growth. There are other fellowships specific to our field that provide unique opportunities to gain valuable skills, outside of further clinical sub-specialization, that aren’t as generally well-known. The purpose of this article is not to convince you of the benefits of a generalist physiatry practice, and it is not written to specifically advocate for any of the programs discussed below. However, I wish to provide some general information for those who are interested in learning more about these programs.
Quality Improvement/Patient Safety
Formal QI activities provide a clear, systematic process to improve healthcare delivery at multiple levels of care, and to organize and communicate those results to key stakeholders. The current healthcare quality, and closely related, patient safety movements have received much attention since the landmark Institute of Medicine reports “To Err is Human” and “Crossing the Quality Chasm” were published at the turn of the century. In addition to the medical benefits of improved patient care and system efficiency, QI will likely continue to play a major role in healthcare delivery in the future with QI requirements for medical education, board licensing/renewal and payment reform models.
I am currently completing a QI fellowship through University of Washington and the Veterans Health Administration (VHA). There are close to 100 CRQS fellows across the country, each practicing within a local VA center. Most of the trainees in our cohort are from internal medicine, and my position is the only one dedicated to PM&R trainees. We meet regularly for national lectures and small group sessions to further develop QI, patient safety and leadership skills. Experiential learning includes various QI projects, research and contribution to various departmental and hospital-wide committees. About 20% of my time is dedicated to patient care activities, which is mainly outpatient EMG. I have loved this experience and would recommend it to anyone!
Healthcare (Rehabilitation) Policy
As the PHiT liaison to AAPM&R’s Quality, Practice, Policy & Research Committee (QPPR), I see firsthand how policy research and advocacy impacts our specialty within the healthcare arena. There are countless opportunities for post-graduate training in healthcare policy across the country through various academic, government and non-profit organizations. Some specialties such as internal medicine and emergency medicine have specialty-specific policy fellowships. The majority, however, are open to a wide range of clinical specialties, including non-clinician postdoctoral fellows. Here is a great resource for various policy fellowship programs.
National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) also supports rehabilitation-specific policy fellowships. These fellowships are designed to include both dedicated research time as well as placement in Washington, DC, either on Capitol Hill or within one of the federal agencies. These are two examples:
Clinical Informatics
The American Medical Informatics Association defines clinical informatics (CI) as the “application of informatics and information technology to deliver healthcare services.” It is the overlap of information technology, healthcare systems and clinical care. In the past decades, multiple legislative efforts have incentivized the implementation and interoperability of CI, largely driving the field to the forefront of healthcare innovation. The further I have progressed within QI, the more I appreciate the importance of CI tools to enhance, and not diminish, patient care and physician satisfaction. CI became a medical sub-specialty in 2011 under the American Board of Preventive Medicine (ABPM) with many new training programs opening since that time.
Two-year CI fellowships are open to any board-certified physician, including those who have completed a PM&R residency program. Depending on the host academic institution, the fellowship can be housed within a variety of training programs; however, most are supported through internal medicine, pediatrics, pathology and family medicine departments. After completion of the fellowship, physicians will be prepared to assume CI-specific leadership roles, including management of the Electronic Health Record (EHR). At this time, there are no fellowships offered through PM&R departments, however, the full list of CI programs can be accessed through the ACGME, AMA FREIDA or AMIA websites.
Research
While research fellowships are often dominated by aspiring researchers that have completed a PhD, physicians provide unique clinical insights and are invaluable as researchers. Typically, research fellowship opportunities are aligned with large, research-oriented PM&R departments or through large healthcare systems, such as the VA. These opportunities can involve research in basic sciences, or clinical and translational research. There can be dedicated clinical time allotted to maintain clinical licensure and skills, but the fellowships are primarily designed to help prepare for a career in research, such as securing grant funding for further endeavors.
The above list is by no means comprehensive. Other specific, non-clinical fellowships available for PM&R residents include training in pharmaceuticals/drug development, healthcare delivery science, healthcare management, bioethics, data science and environmental/climate medicine. If you are ready to enter full-time physician life, don’t worry! You do not need to do a fellowship to be an excellent clinician. Furthermore, there are ample opportunities to gain skills in each of the above disciplines without a dedicated fellowship. You do not need to do a fellowship to apply the steps in PDSA (Plan, Do, Study, Act), to produce great research, or to advocate for your patients and our field through thoughtful policy work. However, many fellowships are designed to provide dedicated time for personal and professional enrichment, as well as an opportunity to build skills early in your career that will be valuable to future colleagues and employers. Good luck as you make these important early-career decisions, including whether to pursue clinical, or non-clinical, fellowship training.